llllllllllllii HX00019500 'V% S*JP:''-i>;M'5L.-"^ irr^:. .•-■^:■:''v^'^■'•• f;^^-%:;;■:;/;'■ ' :s: _x • 602099Ze00 saiuvuan AiisuaAiNn viawmoo r:yte>,:m^;^s^^.<^ i*d^! CLINICAL MANUALS FOR Practitioners and Students OF Medicine. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofbreastOObrya FRONTISPIECE. Nipple Pig. 1. If i Suspensory ligaments. C^' Fig. 3. Fig. 2. 1. Encapsuled Adeno-fibroma. 3. Adeno- fibroma. . 2. Submammary Abscess. THE Diseases of the Breast. BY THOMAS BRYANT, F.R.C.S., M.-Ch. (Hon.) Eot. Univ., I., SENIOR SURGEON TO AND LECTURER ON SURGERY AT GUy'S HOSPITAL; VICE-PRESIDENT, CHAIRMAN OF THE COURT OF EXAMINERS, AND HUNTERIAN PROFESSOR OF SURGERY, ROYAL COLLEGE OF SURGEONS, ENGLAND; CORR. MEM. SURGICAL SOCIETY, PARIS. WITH 13 ENGRAVINGS AND 8 CHROMO-LITHOGRAPUS. CASSELL & Company, Limited london, paris, new york & melbourne. 1887. (all RIGHTS RESERVED.] (CGrvvV PEE FACE. The object of this work is to place before the student and practitioner a clinical exposition of the abnor- malities and diseases of the breast, more particularly with reference to their diagnosis and treatment. With this view the descriptions of pathological pro- cesses have not been placed in the foremost position, and it has been assumed that readers of this volume are familiar with the leading mac?-oscopical as well as ??w'croscopical features of the different varieties of tumours, such as are to be found described in tlie many excellent works on pathological anatomy. The pathological aspects of disease have, however, been referred to, to elucidate its clinical phases, and more particularly to show how the signs and symptoms of local disease are to be explained by progressive pathological processes. To render the clinical aspects of disease clear, brief notes of cases have been quoted, to illustrate either a subject or a symptom ; and with a like object coloured plates have been freely introduced, many of which have been copied from the originals in Guy's Hospital Museum. vi Diseases of the Breast. In preparing this work I have to thank Dr. J. Goodhart for his kind aid in revising the patho- logical portion, and Mr. C. Symonds for some valued microscopical investigations, 65, GrROSYEXOR StREET, Beccmba; 18S7. CONTENTS CHAPTER PA OK I.— Anatomy of the Breast 1 II.— Abxormal Condition of the Breast and Nipples 6 III.— Hypertrophy and Atrophy of the Breast 13 IV.— Inflammation of the Breast . . . . 19 v.- Chronic Abscess of the Breast . . .15 VI.— How TO Examine a Breast— Functional Dis- orders OF THE Breast 55 VII.— ScROFTLOus Swelling (Inflammation) of the Breast G2 VIIL— Syphilitic Mastitis . . . . . . . G9 IX,— Tumours of the Breast .... .73 X.— Adenomata and Adeno-Fibromata : The Fi- BROM.VTA OF GLANDS (A SARCOMATOUS EXCAP- suled Growth) 81 XI.— Adeno-Sarcomata 115 XII.— Carcinoma of the Breast (ax Ei'ithelial Infiltrating Growth) . . . . .182 XIII.— The Clinical Features of a Scirrhous Carci- noma 171 XIV.— Treatment of Carcinoma of the Breast 202 XV.— A Series of Cases Illustrating the Clinical Symptoms and Treatment of Carcinoma of the Breast. Each Case Illustrates a Point 2.35 viii Diseases of the Breast. CHAPTER PAGE XVI.— Cystic Tumours of the Breast . . . .246 XVn.— Galactoceles axd Hydatids 310 XVni.— A Summary of the Diagnosis of Tumours of THE Breast 322 XIX.— On Morbid Conditions of the Nipple . . 326 XX.— On the Presence op More than One Neo- plasm IN THE Same Subject, and on the Shrinkage of Tumours 335 XXI.— N^Yi AND Vascular Tumours of the Breast : LiPOMATA AND ChONDROMATA OF BREAST . 3io XXII.— Tumours of the M.\le Breast .... 350 LIST OF COLOUEED PLATES. PLATE I. ...... . Frontispiece Fig. 1.— Encapsnled Adeiio-fibroma. ,, 2. — Adeno-fibronia. „ 3.— Submammary Abscess. PLATE II. -SARCOMA OF THE BREAST . . To face page 115 Fig. 1.— Sarcoma. „ 2. —Section of harder Variety. ,, 3.— Section of softer Variety. PLATE III.— CARCINOMA OF THE BREAST . ,, „ 139 Fig. 1. —Dimpling of Skin. „ 2.— Puckering of Skin. ,, 3.— Atrophic Carcinoniii. ,, 4.— Tuberous Carcinoma. PLATE IV.— CARCINOMA OF THE BREAST . ,, ,, ISG Fig. 1. — Lymphatic Infiltration of Skin. ,, 2.— Open Tuberous Carcinoma. ,, 3. — Brawny Carcinoma. ,, 4.— Tuberculated Infiltration of Skin. PLATE v.— CARCINOMA OF THE BREAST . ,, „ 193 Fig. 1.— Paget's Disease of the Nipple. ,. 2. — Section of Carcin(Sma. ,, 3.— Section of Sfirrlius. „ 4. — Section of soft Carcinoma. PLATE VL— CARCINOMA OF THE BREAST . „ „ 200 Fig. 1. — Carcinomatous Ulcer. ,, 2.— Section of Same. ,, 3. — Colloid Caicinoma. ,, 4. — Section of Same. PLATE VII.— CYSTIC DISEASE . . . „ „ 24S Fig. 1. — Cystic Disease with Discharging Nipple. ,, 2. — Cystic Sarcoma, ,, 3.— Cystic Sarcoma bursting through Coverings. ,, 4. — Cystic Carcinoma. PLATE VIII „ „ 317 Fig. 1. — Lipoma. „ 2. — Chondroma. " M Hydatids. ,, 5. — Cystic Degeneration of Breast with Sarcomatous Growths. BIBLIOGRAPHY. Brodie ; Lectures on Surg. Pathology ; 1S46. Sibley; Med.-Chir. Trans., vol. xlii. ; 1859. Baker; Med.-Chir. Trans., vol. xlv. ; 1862. Ijutlin ; Med.-Chir. Trans., vols. Ix., Ixiv. T. Annandale ; International Encyclopaedia of Surgery, by Ash- hurst, vol. V. ; 1885. H. Morris; Med.-Chir. Trans., vol. Ixiii. ; Lancet, voL ii. p. 873; 1879. A. von Winiwarter, of Vienna ; Beitriige zur Statistik der Carci- nome; 1880. Richelot ; Des Tumeurs Kystique de la Mamelle ; Paris, 1878. Labbe and Coyne ; Traite des Tumeurs Benignes du Sein ; 1876. Fovget ; Bull. gen. de Therapeute, tome xxvii. p. 359. Conrad Langenbeck ; Nosologic und Therapie der Chir. Krank- heiten, Bd. v. p. 83. Cruveilhier ; Anat. Pathologique ; 1835-42. C. de J\ 'organ ; Patholog. Soc. Trans. ; 1874. Discussion on Cancer. C. Moore ; Influence of Inadequate Operations upon the Theory of Cancer, Med.-Chii\ Trans., vol. 1.; 1867. Velpeau : Traite des Maladies des Sein ; 1854. Also Translation ; Sydenham Society ; 1856. Cornil and Eanvier ; Manuel d'Histologie Path. ; 1869. Alfred Haviland ; Journal of Society of Arts, No. 1,367, vol xxvii • 1879. ■' Handyside ; Journal of Anat. and Phys., vol. vii. ; 1873. Dr. Mitchell Bruce ; Journal of Anatomy and Physiolofiy, vol. xiii. Cameron ; Journal of Anatomy and Physiology, vol. xiii. C. Creighton ; Journal of Anatomy and Physiology, vol. xiv. Leichtenstern ; Virchow's Archiv, vol. Ixxiii. part 2 ; 1878. Cohn ; Berliner Medizinische Gesellschaft, Feb., 1885. Champneys ; Med.-Chir. Soc. Trans., vol. box. ; 1886. Leger; Bull. Soc. Med. d' Amiens; 1878. Ptichet ; Gaz. des Hopitaux, May 13, 1880. Traite d'Anatomie Chirurgicale ; 1857. Ambrosoli ; Gazetta Medica Lomharda, No. 36 ; 1864. B&uVs,; British Med. Journ., Dec. 9, 1882. Harveian Societv, March 3, 1887. Dubar ; Tubercules de la MameUe ; 1881. Durant : Gaillard's Med. Journ. of New York, June, 1884. DarAvin ; Origin of Species ; 1875. Gould ; Medical Society Proceedings ; 1884. xii Diseases of the Breast. Sauvages ; Nosologia Methodica ; 1768. Thomas; New York Med. Joiirn., p. 337; 1882. Thin; British Med. Journ., May, 1881. Munro ; Glasgoio Medical Journal ; 1881. Duhring ; American Journ. of Med. Science, Jiily, 1883. Wagstaff e ; Pathological Society Trans. , London, vol. xxvii. Sir J. Paget ; St. Bartholomew's Hospital Reports, vol. x. ; 1874. Surgical Pathology; 3rd ed. 1870. August Forster ; Die Missbildungen des Menschens ; 1861. Billroth ; Siirgical Pathology ; 1877. Robert ; Journ. Gener. de Med., tome c, p. 57. Csesar Hawkins ; Lond. Med. Gaz.; 1838. Collected Works ; 1874. E.. Lee ; Med.-Chir. Trans.; vol. xxi. S. W. Gross ; Tumours of Mammary Gland ; 1880. Sir A. Cooper ; Anatomy of Breast ; 1840. Illustrations of Dis- ease of Breast ; 1829. Manget ; Diet. Ency. des Sc. Med., tome xiv. AYoodman ; Trans. Obstet. Soc. Lond., vol. ix. ; 1868. Lousier ; Dissert, sur la Lactation, p. 15. Fitzgibbon ; Dublin Quart. Journ., vol. xxix. ; 1860. Max Bartei ; Eeichert and du Bois-Rejmiond's Arch., 1875. Percy ; Diet, des Sc. Med., tome xxxiv. p. 525. Sneddon ; Glasgoio Med. Journ.;^ 1878. Shannon; Dublin Quart. Journ.' vol. v. ; Feb., 1848. Jussieu ; Lancet, vol. xii. p. 618. Philomatic Soc. Froreip's ISTotizen, bd. xxiii. Stettegart ; Langenheck's Archives; 1879. Dr. A. Henry ; Statistiche Mittheilungen iiber den Brust krebs ; Breslau, 1879. H. Lobert ; Des Maladies Cancereuses ; 1851. Birkett ; Diseases of Breast ; 1850. Holmes' System of Surgery ; 3rd ed. 1884. Nunn ; Cancer of the Breast ; 1882. Rudolf Maier, of Freiburg ; Lehrbuch der Allgemeinen Patho- logischen Anatomie ; Leipzig, 1871. C. Creighton : Contributions to the Physiology and Pathology of the Breast ; 1878. Reports of the Med. Officer of the Privy Council, 1874, 1876. "Williams, W. R. ; The Influence of Sex in Disease ; 1885. Goodhart, J. F. ; The Nature and Development of C>stic Tumoiu's of the Breast ; Edinburgh Med. Journal, May, 1872. Berard ; Diag. differ, des Tumeurs du Sein ; Paris, 1842. "Wilks and Moxon ; Lect. on Path. Anat. ; 1875. 4- DlSEASES OF THE BREAST. CHAPTER I. ANATOMY OF THE BREAST. It is essential that the practitioner when examining a diseased breast should always have in his mind's eye the anatomy of the healthy organ. He should remember that the breast is a skin gland situated in the connective tissue between the layers of the superficial fascia ; that the gland itself is en capsuled, with its posterior wall slightly concave, resting and moving upon the pectoral muscle, and the anterior wall convex, separated from the skin by more or less lobulated fat, and at the same time connected with it, in suspended form, by fibrous bands, which are known as the suspensory ligaments of the breast (Plate I. Fig. 1). The boundaries of the gland are not however al- ways very exact, and it is not uncommon, as demon- strated by disease, to find processes, or rather lobes, of the gland projecting into parts which seem to be outside the radius of the normal gland. The fre- quency of this extension from its axillary border is so great, that it may be open to a question whether it may not be regarded as a normal condition. In operations upon the breast this anatomical condition is worthy of remembrance. In thin people there is but little fat between the gland and the skin covering it, and under such B— 25 2 Diseases of the Breast. [Chap. i. circumstances there is an absence of that roundness and plumpness which so characterises the breast of a healthy and well-made woman. On the other hand, in fat women, even when the gland itself from senile atrophic changes has shrunk to very small dimensions, the deposit of fat around, the gland being large, maintains the shape and size of the breast. The presence or absence of fat about the gland has consequently an important bearing in modifying the manipular indications of a healthy as well as of a diseased breast. A small tumour in a thin breast is readily recognised, whereas in a fat one it might be overlooked ; and a scirrhous infiltration of an atrophic breast of a fat woman might suggest the presence of a large tumour, when in reality the bulk of the growth is fatty tissue. The practical bearing of the existence of the sus- pensory ligaments of the breast is very great, since it is by the shortening of these ligaments that the characteristic "dimpling" and "puckering" of the skin, so frequently seen in the infiltrating form of cancer of the breast, is brought about. The gland itself is a conglomerate, racemose, or compound organ, made up of from fifteen to twenty distinct lobes, subdivided into lobules ; the lobules on section presenting a pale pinkish cream coloured appearance. Each lobe is held together by firm fibrous tissue_, and yet at times is separated by fat ; each lobule is surrounded by connective tissue for a support, as are likewise the smaller lobules and secret- ing acini of the gland. This connective tissue may become the seat of connective tissue neoplasms {sarcomata) ; the acini and ducts the seat of adenomata and epithelial {cancerous) neoplasms. Connected with each lobe there is an excretory Chap. I.] Anatomy of the Breast. 3 galactophorous or lactiferous duct, which terminates in the nipple, and during lactation this tube as it ap- proaches the nipple becomes dilated into a sinus or am- pulla, one-quarter or one-sixth of an inch wide, and these ampullae act as reservoirs for the milk when secreted. Each terminal tube opens in the nipple by a separate orilice, which is smaller than the tube, while the small initial tubes or ducts of the acini and lobules unite together, and so help to form the larger tubes as they converge toAvards the ni])ple. The lobes, lobules, and acini of the gland are lined by an almost structureless basement membrane covered with epithelium, and this epithelium varies in character according to its position and to the condition of activity of the glands. In the lactiferous ducts, from the reservoirs to their terminations, the epi- thelium appears as small oval corpuscles with a central nucleus to each ; towards the orifices of the ducts the epithelium tends towards a squamous ap- pearance. In the reservoirs the epithelium is of the tesselated form ; columnar cells are said also to be present by Kolliker and Birkett. When the breast is in an inactive condition the epithelial cells are small and granular, but when physiological activity begins, the alveoli enlarge, and become tilled with a clear secretion. The cells appear flattened out against the membrana propria, or basement membrane, and con- tain fat globules of varying sizes. When the gland is in full activity the epithelial cells become cubical, or even columnar, but are irregular in size, and exhibit indications of segmentation, and discharge into the cavity of the alveoli. "The secretion of the breasts is formed by the bursting of these cells, and the discharge of their con- tents into the alveolus, the fat globules which were present within the cells becoming suspended in the fluid of the alveoli as milk globules, and the albuminous 4 Diseases of the Breast. [Chap. i. constituents of the cells becoming dissolved and forming the casein and other proteid substances of the milk."* " The mature functions of the breast," writes Creighton, " are in effect a sustained repetition of those cellular changes which the embryonic cells went through in order to become the breast," and no doubt the spurious or morbid pathological evolution and involution of the gland is marked by changes in its epithelial or secreting structure, which in a measure or to a degree simulate these changes. In intermediate stages between these two ex- treme physiological conditions, as well as when the gland is in a morbidly active state, changes in the epi- thelial lining of the acini will be visible, analogous to those which take place in the gland in its physio- logical evolution and involution. The blood-vessels of the gland, which are numerous, invest the alveoli, but do not come into direct contact with the secreting cells themselves. In the breast, as in other secreting glands, the vessels lie out- side the basement membrane upon which the epithelium is placed, and according to Schafer are separated from the secreting cells by the lymphatics. Hence, the material for the nutrition of the cells is not drawn from the blood dii^ect, but from the lymph of the breast gland. The arteries of the breast are thoracic branches of the axillary, branches from the aortic intercostals, and the intercostal branches of the internal mammary. There is a markedly free anastomosis of veins, more particularly ai'ound the areola.t The lymphatics from the breast are also numerous ; they are superficial and deep, and pass in two main lines. Those from the axillary and lower half of the gland run to the axilla ; whilst from the sternal half * Quain. f Haller's "Cixculus Yenosus." Chap. I.] Anatomy of the Breast. 5 they pass to the glands situated along the course of the internal mammary arteries beneath the sternum. Lymphatics from the upper part of the gland pass into the cervical region, and not necessarily through the axilla. The nipple (mammilla) occupies a position slightly below the centre of the gland, on a level with the lower border of the fourth rib ; it projects in the virgin state forwards, outwards, and slightly up- wards ; during the progress of a pregnancy it turns downwards. The surface of the nipple is dark, and around it is an areola, which in the virgin is of a light rosy pink colour, and in the prolific matron be- comes dark ; the darkness of the areola commencing at the second month and increasing with every month of pregnancy. As the gland returns after lactation to its quiescent condition the darkness of the areola may diminish, but does not disappear. The skin of the areola is wrinkled and covered with roundish elevations, which are sebaceous follicles known as large and small areola glands ; every gland opens by four or five ducts on each papilla. When the ducts are obstructed a sebaceous tumour may form. The nipple contains some muscular tissue, and the terminations of the fifteen or twenty excretory gland ducts. The central ducts are the larger; and outside the ducts, in the areolar tissue which surrounds them, the blood-vessels ramify. The ducts become narrow at their orifices, and open in the little de- pressions seen in the apex of the nipple. The skin covering the mammary glands receives its sensibility from the anterior and middle branches of the second, third, fourth, and fifth intercostal nerves, whilst the skin over the upper border of the gland is supplied by the supraclavicular branches of the cervical plexus. These points should ever be remem- bered, for pain may follow the course of these ner\'es 6 Diseases of the Breast. rchap. ii. and be experienced over tlie region of tlie breast which they supply, without the existence of any breast disease. The mammary glands are the same at birth in both sexes. The development of the gland takes place in the female at puberty, at or before the first catamenial period. From puberty to the cessation of the catamenia the glands are in the condition of dormant developmental perfection, but this stage itself is reached only when from pregnancy the full physio- logical functions of the gland are called into activity. After the cessation of the catamenia, when the functional activity of the glands can no longer be called into requisition, a period of functional decline commences, which in the healthy subject ends in a simple atrophy of the secreting acini of the gland. At each of these periods certain troubles are prone to appear, to which attention will be drawn in the following chapters. CHAPTER II. ABNORilAL CONDITIOX OF THE BREAST AND NIPPLES. The abnormalities of the breast and nipple show themselves either in the way of excess or of defi- ciency. Those of excess are the more common, and strange as it may seem, they are more frequent in the male than in the female sex. Dr. Mitchell Bruce, to whom we are indebted for an able paper on this subject,* tells us that out of nearly four thousand men and women examined consecutively, sixty-one had supernumerary nipples, forty-seven were males and fourteen females. In a second series of cases, ex- amined exclusively for the purpose, about seven out * " JoTU'iial of Anatomy and Pliysiology," vol. xiii. Chap. II.] Supernumerary Gland. 7 of every hundred consecutive individuals Lad tlie de- formity, and it was found nearly twice as often in men as in women. Five out of six of Bruce's cases had but one supernumerary breast or nipple, whilst the sixth had more than one. Most of the instances observed have been situated on the front of the trunk, below the level of the ordinary mamma, and somewhat nearer the median line of the body than the normal gland. These supernumerary parts were distributed, as ingeniously pointed out by Bland Sutton, in the course of the internal mammary and deep epigastric vessels. In exceptional instances these excesses have been found in extraordinary positions. Again, these supernumerary parts are more frequently found on the left than the right side of the body, in the proportion of sixty to forty per cent. The figures of Bruce, Leichtenstern, and others, clearly indicate this fact. Leichtenstern, in discussing the cause of this curious disproportion, maintains that the left mamma is on an average more developed than the right, and mentions Hyrtl's explanation of this inequality, that it is so because mothers use the left gland more in suckling. He, however, himself maintains that the same condition holds good in the child and virgin, which, if a fact, adds Bruce, is probably an instance of variety " as the inherited effect of use," * and a point of extreme importance in the question of the significance or origin of supernumerary mammse. "We may doubt also," wrote Darwin, " if additional mammae w^ould ever have been developed in both sexes of mankind, had not his early progenitors been provided with more than a single pair." The supernumerary nipple is commonly placed about three inches from the normal nipple. In ex- ceptional cases it may be only about one inch distant, * Darwin, " Origin of Si^ecies," p. 8. 1875. 8 Diseases of the Breast. [Chap. ii. wliilst in others it may vary from three to six inches. But whatever may be the distances in childhood, Bruce has satisfied himself that the distance may increase considerably with age. The characters of the supernumera^ry gland or nipple vary exceedingly. " Some examples," writes Bruce, " might be chosen for description, which in every particular, except size, resemble an ordinary male mammilla, while others require considerable ex- perience for their discovery and identification. The best-marked cases present the central papilla or nipple proper, a pigmented areola, follicles, hair, and a dis- tinct depression on the apex of the papilla. Examples such as these are, however, very rare. The more usual condition is the presence of a small papilla, or elevation more or less like the ordinary male mam- milla, "or a low ovoidal prominence, with its long diameter in the transverse direction, slightly inclined downwards and outwards, and having its summit usually distinctly cleft into two lobes by an opening or deep gTOOve parallel with the diameter, this variety somewhat resembling the retracted nipple of some female breasts." The papiUa of the supernumerary mammilla may frequently be found erectile. The areola of a supernumerary nipple may be entirely absent, or it may be represented by the smallest line of pigmentation around the base of the papilla. In some cases it exists as an areola of natural dimensions and appearances ; in others it is pigmented in variable degrees, whilst in some exam- ples all pigment is absent. Follicles and hairs are not commonly present in the supernumerary nipples. In exceptional exam- ples, however, some strong pale or black hairs are met with. Supernumerary nipples found above the normal Chap. II.] Supernumerary Gland. 9 mammilla are very rare. Bruce says only four cases of the abnormality are on record, and in all of these four the supernumerary was placed outwards as well as upwards from the normal organ. Dr. Fitzgibbon has recorded an example of this kind, in a soldier, aged twenty-four, a native of Jamaica, who not only had two suj)plementary nipples, one on each breast about one inch below the normal nipple, but two pigmentary deposits, one on either breast higher up above the ordinary mammilla?, which were clearly supernumerary nipples. When the man was young the lower supplementary were larger than the natural nipples. When seen by Dr. Fitzgibbon they were smaller. Amongst the cases of supernumerary breast which have been recorded, there are four or five in which five mammary glands existed ; one of these has been minutely described by M. Gorre, as reported by Percy. Four of the glands in M. Gorre's case were very projecting, full of milk, and arranged in two lines; the fifth breast was not larger than the breast of a girl before puberty, and was placed below and in the middle of the body, between the inferior pair, and live inches above the umbilicus. Cases in which four breasts have been seen are recorded by Sir A. Cooper, Dr. Kobert Lee, and Dr. Shannon \ others in which three breasts existed, by Dreger, Bartolin, G. Hannseus, J. Borel, Bobert, and Sneddon. Where these abnormalities exist others are not unfrequently associated with them. Thus, in a girl, aged six, whom I saw in September, 1883, with a supernumerary nipple and areola one inch below the left nipple, there was some malformation of the genital organs ; apparently no vagina, and a clitoris as large as a boy's penis, with prepuce and orifice as of a urethra, which passed down the clitoris for half an inch ; the urethra was normal. lo Diseases of the Breast. [Chap. ii. Percy states that Anne Boleyn, who had six fingers and six toes, had three breasts. Supernumerary glands are sometimes active ; and as a rule it has been from their functional activity during pregnancy or lactation that their presence has been made known. Dr. Bruce had not, however, seen an example of this kind, and in not a single instance would the subject of the abnormality confess to any alteration of the parts in pregnancy or during men- struation. On April 6, 1831, Mr. Roberts, an able prac- titioner, exhibited before a London Society (the Hunterian) the model of a female breast with two nipples. They were a quarter of an inch apart, and the woman was able to suckle by either. It is said, indeed, that in most of the examples recorded when the breast is lateral, the supernumerary nipples emitted milk, but when it is median, this is not always the case. In an instance which has passed under my observation, this was not, however, the condition ; the case was as follows : Supernumerary nipple and breast. Sarah P., aged forty, the mother of eight children, all of which she had suckled, came under my care on September 25, 1862, wTith a supernumerary nipple about two inches below her right breast. The nipj'jle looked quite like the ordinary nipple, but never discharged milk. It did not appear to have any con- nection with the right breast, but the parts beneath it were full, and this suggested the presence of a supernumerary gland. The fact, however, that during her eight pregnancies no milk was secreted proves the contrary. This deformity, like others, is at times hereditaiy, but not being a self-evident one, the fact of its being so is not often to be made out. Both Bruce and Leichtenstern failed to find evidence in any of their cases of heredity, and it is mentioned in only Chap. II.] Supernumerary Gland. ii seven out of the ninety-two cases recorded before these authors investigated the subject afresh. M. Kobert has, however, reported the case of a woman •with a supernumerary breast, whose mother had the same anomaly, and Dr. B. Woodman saw a mother and daughter each of whom had three nipples. Dr. Handyside has reported a case where two brothers liad four breasts each, the two supernumerary glands being placed below the normal mamma, but nearer the median line of the body. Supernumerary mammae are found at times in strange places. Tw^o instances of supernumerary glands have been recorded by Leichtenstern as having existed upon the back. Both have, however, been taken from old works ; one from Paulinus, and the second quoted by Helbig. Leichtenstern accepts the cases as true, and upon his authority I name them. Klob has recorded one case in which the mamma was placed over the acromion process of a man, and was the size of a walnut ; it had also a good nipple. In M. Robert's case the abnormal gland was placed " on the outer part of the left thigh, four inches below the great trochanter, and was about the size of a lemon. It was the seat of pain, and of sensations like those of the normal breasts, at the catamenial periods. The possessor of it had suckled several children with the third breast. The mother of the woman, aged fifty, had three breasts, all in the chest." M. Jussieu reports the case of a woman who had a third breast in the groin, with which lactation was performed. " I know of no case in literature," adds Leichtenstern, " where accessory breasts or mammae have been met with be- low the inferior border of the ribs upon the abdomen." Bruce has, however, recorded in his paper two, if not four cases in which it was clear that the super- numerary nipples had an abdominal position. The existence of axillary mammae cannot be 12 Diseases of the Breast. [Chap. ii. doubted. Leiclitenstern lias recorded five, one of wliicli lie saw. It was in the left axilla, and had asso- ciated with it a supernumeraiy nipple below and internal to the normal one of the same side. A. Forster has recorded a case in which the super- numerary breast was in the axillary region and the seat of carcinoma. A. H. Cameron recorded* a case of a pregnant woman who had an axillary swelling, in which there was a small orifice, but no nipple from which milk could be squeezed. Cohn also, at a meeting of the Berliner Medizinische Gesellschaft in Feb., 1885, exhibited a patient precisely similar to Cameron's. Cameron, in his paper, suggests that if morphological theories fail to explain the abnormality which he had described, we may accept Laycock's view that the mamma is simply an enlarged and highly developed sebaceous gland, and might make its appearance in any part of the body. Since the above remarks were written. Dr. Champ- neys has described, in an able paper on the develop- ment of mammary functions of the skin of lying-in v\-omen,t thirty cases of what he has termed milk-producing tracts of integument, or axillary lumps. These were mostly on the right side when not sym- metrical, and were developed generally pari ^passz^ with the breast. The secretion from the lumps was of three principal kinds : {a) granular debris, like the secretion of seba- ceous follicles ; (h) colostrum ; (c) milk. It was ex- pressed from the situation of the sebaceous follicles, as marked by the situation of the hairs. The whole surface of the lump produced secretion ; there was no centralisation. These axillary lumps seem to prove that in lying-in women the sebaceous follicles of the * " Journal of Anatomy -and Physiology," vol. xiii. t Eoyal Med.-Chii\ Society, AprH 27, 1886 ; Lancet, May 1. Chap. III.] Hypertrophy OF Breast. 13 skin are capable of producing true mammary secre- tions. They confirm the opmion^tliat the breast is a highly, specia lised _ai;m:e2fation of higlily speciaFsed sebaceous follicles. _The least specialised form is that here 'described, where the skin is merely thickened, and the sebaceous glands produce true mammary secretions. The next form is that where there is an aggregation of the ducts which open by one or more external pores. The highest rudimentary form is where an extra nipple or more is superadded to the last variety. It is also well known that nipples may be developed independently. It is far from improb- able, adds Champneys, " that these ' axillary lumps ' may share the pathological affections of the breast, and even be the seat of abscess." I would go farther and add neoplasms, for I believe the existence of these 1 lumps may explain the occasional existence of primary j sarcomatous or cancerous tumours in the axilla, or beneath its anterior fold, which otherwise are difficult of explanation. ' CHAPTER III. HYPERTROPHY AND ATROPHY OF THE BREAST. Hypertrophy. — When a breast gland is univer- sally enlarged it is said to be hypertrophied, and the enlargement is supjoosed to be due to a simple increase in the normal structures of the gland, and not to either an overgrowth of any one of its structures, or to the presence of a neoplasm or new growth. The hypertrophy in the case of the breast is sup- posed to be similar in kind to that of other parts, in which from increase of function there is increase 14 Diseases of the Breast. [Chap. iii. of nutrition, and as a result the elements of the structure grow and multiply to enable it to perform increase of work. How far this analogy is correct may be open to a question, since it is quite certain that in some so-called hypertrophied breasts there is little or no breast secretion, even when the non- hypertrophied gland has been brought into full activity by pregnancy ; and, further, that a large pro- portion of examples of tliis affection is met with in single women, and some examples in male subjects. A woman, aged 43, came under my care some twenty-five years ago ^A\h an enormous right breast, which had been steadily increasing in size for thirteen years; it was when seen at least sis times the size of the left gland ; it hung down heavily, and caused dis- tress from its mere weight. Its nipple was natural. The woman married, became pregnant, and was con- fined naturally. She suckled her child comfortably from the left and unenlarged gland ; the 'right so- called hypertrophied gland gave no milk, and although it enlarged somewhat during the first few weeks of lactation, it neither gave rise to trouble nor shoAved signs of physiological activity. With these facts before us, the enlargement of the breast can hardly with any correctness be called a hypertrophy, since the gland structure itself gave no evidence even of its normal development, much less of any increase in its structure ; and the functions of the enlarged gland, even when stimulated by a com- pleted pregnancy and lactation, failed to come up to the point of normal secretion. Many years ago the same point was demonstrated in the case of a young married woman, aged 25, who came to me with an immense right breast of some years' growth, and a complaint that from some mechanical cause her husband could not have complete intercourse with her. On examination I found she Chap, in.] HvrERTROPlIY OF B RE AST. T^ had a double vagina and a Lifid uterus, and from these facts tlie sexual difficulty of which she complained was fairly explicable. I told the patient that prob- ably a division of the vaginal septum by means of the galvanic cautery would prove of service, and whilst she was considering the point, the question of pregnancy arose, as she had missed a period. The surmise of its possibility turned out to be true, and in due time she was delivered of a boy. The enlarged breast, however, never secreted milk, though the small or normal gland gave abundance. All sexual difficulty had vanished. It is interesting to note that in this case of enlarged breast, as well as in one of supernu- merary nipples previously recorded, the genital organs were abnormal. I have before me notes of five other cases of hypertrophy of the breast which occurred in women, and of four in men. Of the five female cases, four were single and one a married woman ; the latter was 33 yeai'S of age, and the right gland was aflfected. Of the single women, in three the ages were respec- tively 19, 21, and 25 years, and the left gland was the one involved ; in the fourth case the girl was 17, and both glands were implicated. One of the single women, aged 21, had a sister under my care for a large adeno-sarcomatous tumour the size of a cocoanut, which I successfully removed. In two of the five cases the catamenia were quite regular, in three this was not the case. Of the four male subjects, one was a tailor, aged 25, and his left breast was as large as a well-grown woman's ; one was a hatter, aged 3 1 , the affection was in his left breast, which was as large as an orange ; it had been growing for six years ; the third case was a man, aged 20, the right breast had been increasing for three years in a painless way, and was the size of a fist \ the fourth case was in a boy, aged 1 8, and his i6 Diseases of the Breast. [Chap. m. left breast, which had been growing for two years without pain, was the size of half a large orange. It is worthy of note that of the ten cases recorded in which one gland was affected, in six it was the left. The most striking example of this affection I saw in 1865 with my friend Mr. Shipman of Grantham. It was in a single woman aged 1 9, and both breasts were affected. They had been increasing for a year and a half, and were removed, at an in- terval of three months of one another, by Sir W. Eergusson. One specimen is now at the College of Surgeons (Prep. 4,739). The gland on removal mea- sured one foot in dia- meter, and weighed thirteen pounds. Ex- cept in its increased size and in the corre- sponding size of the blood-vessels, which (in the preparation) have been injected, there is no apparent change from the normal condition, although on microscopical examination the normal glandular structure was found to be mixed with a gTeat increase of fibrous tissue. The engraving above was taken from this patient. The reader should remember that this affection may be simulated by the presence of new growths, such as lipomata, enchondromata, or adenomata. In the Guy's Hospital Reports for 1841 (vol. vi. p. 203), a case of this supposed trouble is reported, which Fig. 1.— Hypertropliy of Breast. Chap. III.] Atrophy of Breast. 17 turned out in 1843, when Mr. Stanley removed it, to l)e an adeno-fibroma.* No treatment appears to have any effect in these cases except excision, wliicli is to be performed only Avhen the local afFection is a source of serious trouble. There is no evidenc e to show that this so-called hypertrophy of the breast ,has_MiyiJ2Qim^cti_^onjrtd^ in fiammat ion. The breast in these cases, in both male and female subjects, may occasionally be more tender tlian the unenlarged gland, but this symptom is not alwa3"s present. In the cases of inflammation of the breast in the male subject recovery generally follows treatment, and I have not seen one instance in which such enlargement became permanent. Atrophy of the breast. — By this term is meant the diminution in size due to a wasting of the secreting structure of the breast, the result either of old age, or of some antecedent inflammatory or other change by V/'hich the nutrition of the gland has been interfered with. "When it accompanies old age, it is a physiological and consequently a natural process ; the breasts with the procreative organs Avasting like other glands as soon as they have played their parts in the animal economy, and are no longer wanted for active service. AVhen it occurs during the functional activity of these same organs, the wasting cannot be so explained ^ and the conclusion has to be drawn that the gland lias either not been fairly formed to perform its func- lions when called upon, or that some pathological change has taken place in it by which its secreting power has been crippled or destroyed. The former explanation is illustrated when a breast which is apparently healthy fails to develop and secrete milk during pregnancy, and the subsequent lactating period (agalactea) ; and the latter, when a breast which * Vide Museiim at the College of Surgeons, Prep. 399. c— 25 i8 Diseases of the Breast. [Chap. in. has once performed its functions normally becomes the seat of inflammation, possibly of supjDuration, and recovers, and then fails to respond to the physiological demand made upon it by another pregnancy. In the wasting of old age, there may be no ex- ternal or visible signs of atrophic changes, the development of fat in and about the gland rendering the actual state of the part obscure; never- theless, on making a section of such a breast, the anatomist will often find a difficulty in distinguish- ing the gland, since what remains of it will con- sist mainly of the nipple and its ducts radiating into the fatty and fibrous tissue with which it is surrounded, the ducts often containing a thick mucus. The surgeon also will frequently be surprised to find, when removing a breast the seat of an infil- trating carcinoma, how limited the disease appears to be, although the mass removed may have appeared large ; the infiltrated and contracted mammary gland presenting on section a limited tumour sur- rounded with fat (Plate Y. Fig. 3). In the museum of the College of Surgeons there is a specimen (Prep. 4,819 b) of extreme atrophy of the gland which I removed in 1883 from the person of a lady, aged 65, supposing it to be a carcinoma. It is described in the catalogue as follows : " An ex- tremely atrophied breast, two and a half inches in diameter, of which the nipple is enlarged by a growth of dense fibrous tissue, both Avithin and beneath it, and is pyramidal in shape. The other parts of the gland are of firm fibrous texture, but are less dense than the nipple." With the microscope, only fibrous tissue and a few compressed, atrophied ducts, but no cancerous growth, could be found. Protracted or frequently repeated lactation is often followed by a rapid diminution in the size of the glands, and in exceptional instances even to their Chap. IV.] Inflammation of the Breast. 19 apparent complete loss. In some cases this rapid wasting is real, whilst in others the breast gland, although apparently gone, rapidly re-appears under the stimulus .of a pregnancy, and becomes in due time well prepared to discharge fully its natural functions. Some breasts, likewise, that have been the seat of an inflammation, or of a limited suppuration, are rendered permanently unfit for duty ; whilst, on the other hand, glands that have been scarred all over from abscesses and incisions, and which might be sup- jiosed to have been so injured as to have been rendered physiologically useless, re-assume, on the re- currence of tlieir natural stimulus (pregnancy), their lactating functions ; indeed, such breasts seem to secrete more fully than others that appear larger. The size of a breast, jyer se, is no real indication as to its secreting power, small glands frequently yielding more milk, and more readily, than large ones. When tumours develop in a breast, its secreting functions may not be much interfered with, for I have known women with adenomata suckle freely, and one with a cancerous breast nurse as well on the affected as on the sound side. CHAPTER IV. INFLAMMATION OF THE BREAST. This affection occurs at all periods of life, and in every condition of the organ ; that is, it may be met with even in male or female infants soon after birth ; in boys and girls at the age of puberty ; in w^omen who are pregnant or lactating ; as well as in any subject male or female, who may have been locally injured. 20 Diseases of the Breast. [Chap.iv. Traumatism, under all circumstances, has a powerful influence in exciting the afFection, and the more so when the gland is in a condition of functional ac- ti^dtj. In exceptional cases the afFection may occur in men or women without any assignable cause. The inflammatory action may be acute or chronic. Ifc may terminate in resolution, or in the formation of an abscess. It may involve either a single lobe of the gland, or the whole organ. At times the inflamma- tion will involve rather the periglandular areolar tissue than the gland tissue itself ; on still rarer oc- casions it will aflfect the connective tissue behind the gland, and give rise to a retro- or submammary, abscess. I propose, therefore, to consider this affection under three headings, as it is met with during the period of infancy, at iniberty, and during loregnancy and lactation. Inaammation of the breast as seen in infants. — This is by no means an uncommon affec- tion, and although it may occur without any assign- able cause, it is, in the majority of cases, due to the rough manipulations of nurses who have not wholly escaped the unenlightened influence of the " Gamp " school, and think it right either to " rub away the milk," or " break the nipple strings " of infants three or four days old, a practice which has only to be alluded to to be condemned. It should be well known that the breasts of infants of both sexes during the first few days of life not infrequently contain a secretion of milk somewhat similar in character to that of the mother ; that is, it is made up of fluid containing colos- tric bodies and milk globules in different proportions. The breasts under these circumstances become full, and, as a consequence, tender, and at times a milky fluid escapes from the nipple. The glands are fullest from the fourth to the seventh day, and after that, if left Chap. IV.] Inflammation of the Breast. 21 alone, they gradually empty. In exceptional cases they may increase in size, inflame, and suppurate; and, should they be roughly manipulated, squeezed, or rubbed, these changes are almost sure to follow. The majority of cases of irritable or inflamed breasts in the infant, if rightly treated by soothing warm sedative applications, such as the subacetate of lead and opium lotion, and protected by cotton wool from external pressure, generally do well. The cases that suppurate come to the surgeon, and in these the breasts have usually been roughly treated. When they suppurate they must be opened, drained, irrigated by some iodine or other antiseptic lotion^ and treated as an ordinary abscess. In 1864 I saw a female infant, aged two weeks, with inflammation of both mammary glands, and the inflammation had clearly followed rough manipulation. The glands were much swollen, and the nipples were quite depressed in the centre of the swellings. One breast (the right) suppurated, the left recovered by resolution. The nipple, however, remained retracted. I give this case as an example of retraction of the nipple from early inflammatory action, believing that such cases may be more common than is usually believed. An abscess may, however, occur in a child's breast at a later period than a month. I saw one in 1868 in a female, and apparently healthy, child eight months old. The left breast was acutely inflamed and it had become so a week before without any known cause. The gland suppurated, and wa^s opened and treated with a good result. liiflainmation of the breast as met with at puberty. — At the age of puberty, even in the male subject, there may be signs of increased activity in the mammaiy gland, as indicated by greater ful- ness of the breast, with tenderness ; of darkening of 22 Diseases of the Breast. [Chap. iv. the areola and nipple. Occasionally this increased action goes on to inflamraation and suppuration. In the female subject, remarkable structural evo- lutionary charges take place in association with the growth and development of the ovaries and sexual organs, and under such circumstances there are fre- quently present external and visible signs of this activity, which may last either for a brief period, and then disappear never to return, or may reappear with more or less force at every return of the catame- nial period. Should anything occur from without, such as injury, or from within the gland during its active growing time of life, to interfere with natural evolutionary changes, inflammation may ensue, and either subside or end in suppuration. It is, how- ever, a rare event for a breast, daring the period of its development, to suppurate. On June 2, 1862, such a case came under my care in the person of Fanny K, a healthy looking girl, aged 15, in the form of an acute abscess in the right breast. It had commenced without any known cause two weeks previously, that is, on the sixth week after her first catamenial period. The breasts had, during the whole of this time, been swollen and painful, but the left ceased to be so as the right inflamed. When I saw her the abscess was pointing, and it seemed to have involved the whole gland. It was opened by means of incisions radiating from the nipple, and treated on ordinary principles with tonics. In three weeks she was well. I have the notes of a like case which occurred in the right breast of a girl, aged 13, in whom the abscess and the appearance of menstruation were concomitant. When the catamenia are established, and the breast gland has reached virginal developmental per- fection, inflammation and suppuration are more com- mon. It may occur as an acute or chronic aflection, Omp. IV.] Inflammation of the Breast, 23 and possibly the latter is tlie more frequent. In the majority of cases no adequate cause for the trouble can be found ; in some an injury has been clearly the cause. Under both circumstances the inflammatory action more commonly attacks the whole gland than a single lobe. In some cases it involves both glands. Illustrative cases of this affection will possibly here best pi-oye of value. Acute abscess in both breasts of a girl, aged 15. — Maria C, a healthy looking girl, aged 15^ who had menstruated for two years, always with pain, applied to me in June, 1865, with an acute abscess in her right breast of six days' formation. There was no history of a blow. The abscess was opened and healed. Two years later, on April 22, 18G7, the girl came again with another abscess in her otlier breast of nine days' standing. This was treated by incision and tonics with a good result. Acute abscess in virgin breast. — Mary S., aged 16, came before me at Guy's Hospital on May 10, 1858, with an abscess in her right breast, which had been discharging for one week, after acute inflamma- tion of three weeks' standing. The abscess appa- rently involved half the gland. No blow or known cause could be assigned for its existence. The cata- menia were regular. The opening, being insufficient for the free discharge of pus, was enlarged, and the cavity of the abscess washed out. In one month the girl was well. Chronic inflammation of both breasts in a virgin. — Emma S., a healthy looking girl, aged 15, came under my care on July 7, 1861, for chronic inflamma- tion of both mammary glands. She had menstruated but twice, and it was after the last period, on March 29, that her breasts began to enlarge. When seen the breasts were swollen, hard, hot, and painful. There 24 Diseases of the Breast. [Chap. iv. was also some vaginal leucorrlioea. Fomentatioiis were ai^plied, and iron given as a tonic, and in the course of a few weeks the swellings had subsided. In many cases a breast may inflame without in- jury or known cause, and recover by resolution with- out suppurating. In the one I am about to record, the inflammation never went beyond the cedematous stage, and then passed away. It is the only exam|)le of the kind that I have met with. For this reason I record it. Tlie case explains the treatment that should be employed under similar circumstances. GEdema of hreast {inflammatory ?) ; recovery. — Ellen O., aged 19, a single woman, consulted me on July 25, 1864, for a great enlargement of her left breast, which had been coming on for four months. The whole gland was swollen, and the integuments jDver it were thickened and tensely cedematous, but neither red nor hotter than natural. No cause was assigned for the trouble. Some punctures were made into the tense skin, and much serum exuded. In one week all swelling had disappeared, and in a month the girl was well. Iiiilaiuiiiatioii of the breast diiriiig: pregr- nancy and lactation.— Inflammation of the breasts is most frequently met with in women who are, or have been, suckling. It but rarely takes place when the mammary glands are undergoing their physiolo- gical changes preparatory to suckling. When the breasts are preparing to discharge their normal func- tion, there may, in the early months of pregnancy, be symptoms and signs of increased activity, but such rarely lead up to inflammation, unless stimulated by some external injury. Out of one hundred and two consecutive cases of abscess of the breast which have passed under my observation, seventy-nine occurred during lactation, two during pregnancy, and twenty-one in patients who were neither lactating nor pregnant. Ch;ip. IV.] I.XFLAMMATION Uh 'HIE BrEAST, 2"^^ Thus, roughly stated, four out of every five cases of abscess of the breast occur in lactating wotnen. The right breast seems to be more frequently affected than the left. In uiy own patients this was the case in the projiortion of five to three. Birkett states that this complication of lactation occurs chiefly in women who have given birth to a first or second child. That half the cases are asso- ciated with defective nipples, and another fifth with women whose nipples are unhealthy. Thus, he adds, " we have more than two-thirds of the cases of inflam- mation and its results complicated with, and probably excited by, malformations or diseases of the aggrega- tion of the excretory ducts constituting the nipple." The affection commences usually during the early or late months of lactation. In two-thirds of my own cases it occurred during the early periods, that is, in the first two months ; and in two-thirds of these during the first month. In the remaining third it commenced during the last month. Mr. Birkett's statistics sup- port these conclusions ; fifty-eight out of his one hundred and sixteen cases having commenced during the fourth month after parturition, eleven during the second, and forty-seven during the later periods. It would thus appear that inflammation of the breast is mostly in tlie early months due to some ab- normality or affection of the nipple which renders suckling difficult, if not impossible ; and in the later it is probably due either to protracted lactation, and to the exhaustion of the mother's general and of the breasts' special powers to secrete milk, or to the abrupt discontinuance of suckling from the death of the in- fant or other cause. In some of the cases I believe, with Mr. Ballard, that abscess in the early months is due to the searching of the child after milk before the gland is filled, in patients who have not suffi- cient power either to secrete milk or to resist the 26 Diseases of the Breast. [Chap iv. inflammatoiy process when once origmated. In others, again, it is brought about by the injudicious use of a milk pump. In fact, whenever "the mamma, in its state of full expansion and perfect functional activity, becomes the subject of an interference, the result is very commonly a diffuse or nodular inflammation, and the formation of an abscess. A sudden stoj^page of the milk soon after the lactation has been estabhshecl is apt to produce inflammation, and the same result, or a degree of it, sometimes follows the weaning of the child after a long course of suckling. The dis- turbing cause, whatever it may be, acts upon the mamma when its function is at its greatest intensity, and the characteristic effect is inflammation and abscess " (Creighton). Symptoms of Inflammation of the Breast. As congestion of the blood-vessels is the earliest pathological change in the tissues of a breast that is about to inflame, so a greater fulness, with more or less induration of the affected part^ is the earliest symptom. When the action is confined to a lobe of the gland the increased fulness will be local ; when it involves the breast as a whole it will be general. This symptom of fulness will be readily detected on comparing the sound with the affected side. With this early symptom there may or may not be 2?ain, unless uneasiness of the part, aggravated by movement of the arm, local pressure, or suckling can be called pain. But as the disease jDrogresses, pain will soon manifest itself, and its intensity will turn upon the activity of the affection, or the nervous sus- ceptibility of the patient, but more particularly upon the tension of the inflamed lobe or gland. This tension of the inflamed part is determined by the seat and amount of eftusion poured out by the Chap. IV. 1 Symptoms of Inflammation: 27 inflammatory action, or by the ra])idity with which it has been ettused. With these early local signs there will probably be some constitutional symptoms, as shown by in- crease of temperature and the general disturbance of all the functions of the body, which usually accom- pany every febrile action. At times, even in the very early stages of the afi'ection, a sense of chilliness may precede the local trouble, and in rarer cases a dis- tinct rigor may occur; but this latter symptom is more frequent in women who are suckling than in others, as in them the local congestion and inflamma- tion of the breast is usually preceded by some local disturbance of the breast, and this local disturbance gives rise to rigor. In lactating women local congestion of the breast is not uncommon. It may either subside without giving rise to any true inflammatory action, or pass on to acute suppuration, the ultimate issue of the case being much determined by the treatment it receives. When it occurs, it is commonly called a lum]), knot, or coring of the milk, and the lump or knot is essentially a lobe of the breast, which is choked with milk or its more solid constituents ; this is commonly called lobal congestion. In more severe cases, all the lobes become thus affected, when the aflection is called "lactic congestion." If this local congestion of the breast does not pass on to inflammation, the skin over the gland will remain healthy, and beyond some fulness of its veins appear normal. The congested gland or lobe will, moreover, not be tender ; indeed, it may tolerate manipulation freely, and find benefit from gentle friction, the friction apparently rendering the in- duration less marked, and relieving the congestion. When this congested condition of the lobe or gland 28 Diseases of the Breast. [Chap. iv. passes on to inflammation, the action is, as a rule, acute, and the induration of the part primarily involved spreads to the tissues around, and gives rise either to oedema^ or to a brawny infiltration of the surrounding structures. When the inflammatory action spreads forwards, the skin over the aflected gland will become swollen, red, and more or less oedematous, tense, and painful, and with these local symptoms there will be the constitutional disturbance of inflammatory fever. Wlien the parts hehind the gland are more in- volved than its coverings, there will be the same con- stitutional symptoms as have been described as attending the more superficial inflammation, but the local symptoms will be somewhat different, the difference being due' to the presence of the inflam- matory products behind instead of in front of the gland. From this cause there v\dll be less superficial redness and swelling, but a greater prominence of the breast {see Plate I. Fig. 2), and a sense of deep instead of superficial effusion. The progress of the affection will also probably be slower, and there may be more pain. Should the inflammation continue, or rather not recede, and suppuration take place, many varieties of abscess may be met with, the position of the abscess being determined by many causes. Thus, there may be a local abscess confined to a single lobe, or a diffused one involving the whole or more or less of the gland (intraglandular abscess). In some cases the suppura- tion will appear to be superficial, and confined to the connective tissue between the gland and its coverings {superficial abscess) ; whilst in others it will be placed behind the gland between the breast tissue and the pec- toralis major, and develop as a submammary abscess. In rare cases the abscess forms independently of the breast, as in the cases reported farther on, but in the majority the breast gland is involved in it. The Chap. IV.] Abscess. 29 jn'ogress of the affection under these different circum- stances will vary, and this variation consequently claims some little attention. Superficial abscess. — When the abscess is superficial^ the progress of the affection from tiie first will probably luive been rapid, and although marked with the well-known local phenomena of indammation, it is unusual for it to be accompanied by any severe pain, or associated with general constitutional symptoms. This mildness of symptoms is explicable by the fact that there is little tension upon the tissues, the skin readily yielding to the inflammatory eftusion. Should, however, the inflammatory action involve a large pro- portion of the connective tissue which surrounds the mammary gland, there may be both severe local as well as general disturbance. In feeble and cachectic subjects this extension of mischief is very apt to take place, when from any cause a local inflammation has been started about the breast. Under all circumstances a superficial abscess is prone to be followed by destruction of skin ; when the suppuration is diffused, this destruction may be extensive. In patients of average power, a local inflammation terminating in suppuration may run its course, point, and discharge, rapidly, and with little loss of substance. IiitTag:laiic1iilar abscess is a far more serious trouble than the last variety, since its position is in one or more of the lobes of the gland itself ; and it is to be remembered that these lobes are surrounded by a fibrous fascia, which when distended must give rise to pain. This affection is consequently attended from the first by com])aratively severe local as well as constitutional symptoms. The inflammatory action, moreover, since it in- volves deep structures, is comparatively slow in its pro- gress, or rather, it is slow in developing the symptoms 30 Diseases of the Breast. [Chap. iv. wbicli are usually regarded as typical of a local inflammation ; for to demonstrate these, the action which originated in the gland has to spread through its fibrous envelope to the surrounding tissues, and from them to the skrii. Thus it is that in this form of inflammation many days, or even weeks, may pass in which there may be deep mammary swelling, in- tense local pain, and severe constitutional disturbance without local redness or any marked external evidence of cutaneous implication. These superficial paljDable symptoms only show themselves when the inflam- matory action has ]3assed through the fascial envelope of the afiected lobe of the gland, and secondarily involved its cutaneous coverings. The local pain in the early stage of this true mammary inflammation is often intense ; it is the direct result of tension of the tissues into which the inflammatory effusion has been poured, and it continues until this has been re- absorbed, or the fascial covering of the affected lobe has yielded to the pressure from within and allowed the pent-up fluid to infiltrate the surrounding parts. During the early progress of this aflfection the con- stitutional symptoms are correspondingly severe ; indeed, within two days of the earliest discovery of an indurated and inflamed lobe of a lactating gland, symptoms of acute pyrexia may appear, and they are frequently associated with serious brain excite- ment and disturbance. As the local aff'ection progresses and tends towards suppuration, the local and general symptoms alter, although as to their intensity they rarely diminish. The severe burning lancinating pain which ushered in the trouble, changes into a heavy and distressing throbbing pain, and a rigor is superadded to the general condition of pyrexia. Indeed, from this stage of the aflfection, onwards, periods of fever, rigors, Chap. IV.] Abscess. 3 r and sweating follow one another. The original scat of hardness in the breast steadily increases, until a greater part or the whole of the gland becomes equally involved ; and the breast at this stage of the trouble feels large, and irregularly indurated, with the skin ov^er it uninvolved, and the nipple often retracted. As the abscess progresses, the skin over the breast will become involved, showing redness and oedema ; or even before, if the breast is carefully examined, the surgeon may detect at the original seat of induration a soft and painful spot^ which to the experienced finger at once reveals the fact that the abscess is coming forwards and will soon burst. As soon as the abscess has burst, relief to both local and general symptoms is at once experienced, and in the most favourable cases repair sets in, and i-ecovery is not far distant. To illustrate this subject J append a few typical cases. Acute abscess of breast coming on during the seventh month of iwegnancy. — Susan G.^ aged 26, the mother of four children, all of whom she suckled without trouble, came to me on January 15, 1866, with an acute abscess in her right breast, which had been coming two weeks. She was then pregnant seven months. The abscess was treated by incision, and rapid recovery took place. She subsequently had a natural labour, and could suckle with the breast which had been affected. Abscess in the breast during the third month of preg- nancy, loith retracted nipple. — A woman, aged 37, the mother of one child three years old, came under my care on March 13, 1867, with a tumour in her left breast of six weeks' standing ; the nipple had been retracted three weeks ; there were also enlarged axil- lary glands ; she was pregnant three months. On April 2 the swelling, becoming fluctuating, was opened, and pus evacuated. By May 9 the abscess 32 Diseases of the Breast. [Chap, iv. liad healed, lea^diig tlie gland iudiirated 3 the preg- nancy continued to the end. Chronic abscess in the breast ; recovery ; two years later acute abscess in the same breast after pregnancy. — Eliza F., aged 32, the mother of four children, the youngest l3eing two years old, came to me in Sep- tember, 1867, with a swelling in her right breast of eight months' standing. She had never suckled with her right breast, as the nipple was tender. The nipple had discharged a watery fluid up to the last month. The axillary glands were enlarged. The swelling was globular and semi-fluctuating. The tumour was punctured and eight ounces of pus escaped ; it was then laid open and rapidly cured. On Januaiy 4, 1869, the patient returned with an abscess in the same breast of five weeks' standing, which had followed labour nine months previously, though she had not suckled. This was opened later on and a good recovery followed. Abscess in breast following inability to suckle on account of deformed nipples. — Henrietta D., aged 25, came under my care in January, 1879, with an abscess in her right breast. It had followed closely upon her confinement' nine weeks ago, and was clearly due to her inability to suckle on account of depressed and deformed nipples. She had had plenty of milk. Both breasts inflamed, but the right alone suppurated, and burst, discharging a pint of pus. The left breast recovered by resolution Intraglandular abscess follovAng ulceration of the ni-pple. — Rosie F., aged 35, the mother of four children, the youngest being thirteen weeks old, came into Guy's in February, 1874, with an abscess involving the outer half of the left breast. She had not been able to suckle the last child with either breast on ac- count of sore nipples. On admission, the nipples were extensively ulcerated, and in the outer lobe of Chap. IV.] Abscess. 33 the left breast there was clearly an abscess, as indi- cated by the presence of a deep fluctuating swelling and redness with oedema of the skin over it. There was likewise much pain and general disturbance. An incision was made into the abscess, which was then washed out and drained, and in about a month the woman was well. It seems that with her first child, born fourteen years ago, she had an abscess in her right breast, wliich broke in six weeks and slowly recovered. Her second child she nursed at both breasts. With the third the left breast suppurated. Abticess in both breasts consecutive, retracted nipples as a result. — Rachel B., aged 28, a married childless woman, came under my care on November 10, 1864, with a globular swelling in the centre of her right breast, and a retracted nipple. The swell- ing had been coming on a week, and the nipple had become retracted during that period. The left nipple was normal. In a few days fluctuation was discovered, and the abscess was opened. Three months later the patient came again with the same condition of her left or opposite breast, and a retracted nipple. This likewise suppurated, and was treated. Both nipples were however retracted subsequently. Abscess in the virgin bi'east of a woman, associated tuith retracted nipple. — Charlotte C, aged 25, a single woman, came under my care on May 5, 1885, with a swelling three inches by two and a half in the centre of her left breast, which had been coming for three weeks. It was hard and tender to the touch. The skin over it was natural. Nipple retracted, this retraction began with the swelling and shoot- ing pain ; no enlarged axillary glands. The tumour was supposed to be inflammatory, cold was applied by means of a Leiter's metallic coil for several D— 25 34 Diseases of the Breast. [Chap. iv. weeks with advantage, the swelling diminishing ; as soon as it was given up the swelling, however, in- creased, and an abscess formed, which was opened, drained, and cured. Nodular tumour (injiammatory) in centre of hreast simulating carcinoma, folloK'ing lactation, ivMch disajyj^eared under treatment— Fhc^hQ T., aged 30, a married woman, the mother of one child, now four- teen months old, came to me on October 21, 1861, with a central tumour in her left breast which had been pronounced to be cancerous. It had been com- ing for five months, and had appeared three months after giving up suckling. It was not very painful, but was nodular. The nipple was natural. There was no redness, and but little pain. It was treated as one of inflammatory origin, and strapped up. Tonics were also given. In the course of about two months the swelling disappeared. Subinanioiary abscess is, as a rule, still slower in its progress than the intraglandular ; al- though, in exceptional cases, it may be comparatively acute. It is characterised by a remarkable projection of the breast forwards from its thoracic attachments (Plate I. Fig. 2), and on manipulation, and more par- ticularly on applying pressure backwards upon the sland, a sense of elasticitv and fluctuation will be detected, which is most characteristic. The skin covering the breast at this time may be natural, and there will probably be no change in the appearance of the nip}>le. Pain will rarely be severe or constitutional symptoms serious. As the abscess spreads, and by making its way to the surface involves the integument, both local pain and constitutional symptoms become aggravated. The periphery of the gland will probably be the seat of pointing, and as a rule, the area of redness will be extensive ; it may at first show itself in two or more local red patches, Chap. IV.] Abscess. 35 T)ut these areas of redness will soon unite, and per- chance spread in all directions ; a'"ter a time the skin will give way by ulceration and sloughing, and the abscess discharge itself. The orifices of discharge are generally multiple. In exceptional cases the abscess discharges tlirough the gland, when the orifice is placed near the sternal side of the nijiple wliere the gland is the thinnest. Acute submammary abscess after delivery ; death from lobar p^ieiimonia. — Alice P., aged 22, was ad- mitted into Guy's Hospital on February 11, 1875, with a submammary abscess of her left breast. It had come on after her confinement Six weeks previously. The left breast was not apparently larger than the right, although it stood out from the chest in a very prominent way ; deep fluctu- ation beneath the breast was to be felt. An in- cision was made into the abscess at the lower margin of the gland and much pus evacuated ; in a few days a second incision was made higher up. Chest symptoms soon appeared, with great elevation of temperature, and the patient sank. At the post-mortem it was found that the woman had died from lobar pneumonia of the left lung ; that a large abscess cavity existed between the left breast and the pectoral muscle ; and that the breast itself was quite healthy. All the other viscera were healthy. When this affection has been allowed to run its natural course numerous sinuses are often present, their orifices being situated around the margin of the gland. Sinuses in both breasts following submaminary ab- scesses two and a half years previously, treated by binding the arms to the sides. — Mary M., aged 43, the mother of five children, the youngest being four years old, came under my care on February 21, 1861, with both breasts riddled with sinuses discharging pus, the 36 Diseases of the Breast. [Chap. iv. orifices of the majority of the sinuses being at the periphery of the breasts. These had existed for two and a half years, and had followed acute suppuration of both glands after prolonged suckling. No treat- ment had been successful. The sinuses were syringed daily, and the breasts, strapped. Tonics were also given. Im])roYement followed, but no cure, until the arms were bound to the sides to prevent muscular movement, after which a rapid recovery ensued. Treatiiieait of iuHaniniation of tlie breast. — InliaDimation of the breast is to be treated upon the same principles as inflammation of any other organ ; the object of the surgeon being, if possible, so to check the action in its early stage as to bring about a recovery by resolution, and where this de- sirable end is not to be secured, to limit the amount of mischief in the gland, and to prevent, when sup- puration has taken place, more damage to the gland and surrounding structures than is unavoidable. It must, however, always be remembered that the breast gland may inflame under very different physiological conditions, and that the treatment of an inflamed gland ia a state of physiological inactivity must diflier in a degree from the treatment of one either preparing for lactation, as in pregnancy, or in fall physiological action, as during suckling. The puerperal or non-puerperal condition is a con- sideration which should therefore ever weigh with the careful surgeon, and in the consideration of its treat- ment it consequently seems to be wise to divide cases of inflammation of the breast into two classes. The first including such as occur in children and women quite independently of the puerperal state. The second those that are associated with, or follow, either pregnancy or suckling. Ill infaaits. — Inflammation of the breast in the non-puerperal state, as it occurs in infants, should Chap. IV.] Treatment of Inflammation. 2>1 not give rise to any serious trouble ; and it may probably be said with truth, that it would hardly ever occur, if the breast had not been squecized, pressed, or damaged, by the fingers of rough nurses who are imbued with wrong impressions. Should, however, any inflammatory action show itself, the application of a pad of Gamgee tissue or absorljent cotton dipped in warm lead lotion, will, as a rule, cause it to disappear without suppuration. To prevent a recurrence of the action, the bieast should be protected with cotton wool, and due atten- tion paid to the dresses, that they should not press or irritate the part. When suppuration has taken place the abscess should be opened as soon as it has formed, the punc- ture or incision being made in a line radiating from the nipfle. The abscess cavity should be well washed out with iodine water, that is, a lotion composed of about two drachms of the tincture or one of the liquor iodi to a pint of water ; and some simple dress- ing should be subsequently ajDplied, such as a piece of folded lint saturated with a mixture of terebene (one part) and olive oil (four parts) ; and bound over all a small sheet of Gamgee tissue. With such treatment the abscess will heal. When burrowing has taken place, and the contents of the abscess do not pass away readily, the cavity should be washed out daily with the iodine water ; in exceptional cases a drainage tube may be required. In girls. — When inflammation attacks the breasts of girls at the age of puberty, when they are in a state of evolution, the local application of warm lead lotion, with or without the addition of opium in solution, in the proportion of five grains of the extract to an ounce of lead lotion, will always be beneficial ; wdien the action is high, saline purgation is useful, and when the patient is weak, tonics 38 Diseases of the Breast. [Chap. iv. may be called for, quinine being the best. As the acute stage subsides, tlie local application of the extract of belladonna diluted with glycerine, or rubbed down with vaseline or lard in the proportion of 5i to an ounce, soothes the pain, and expedites recovery. In painful breasts, in which inflammation may be expected, this local application of belladonna may be all that is called for. In all cases of inflam- mation the arm is to be fixed to the side, to check action of the pectoral muscle upon which the breast rests, and the inflamed mammary gland should be supported. In severe cases, where suppuration is threatened, the horizontal position should be main- tained. In iTonien. — Inflammation, as an acute affec- tion, when it attacks the breast of women who are neither pregnant nor lactating is usually the result of injury. It occurs, however, without any such cause. It is, as a rule, periglandular ; when intraglandular it is usually chronic. It is to be recognised by the same symptoms as have been described above, and it should be treated on like principles. When it first appears, it may however be checked by the local use of cold, applied as an ice-bag, or by what is better, Leiter's metallic coil, a method of treatment which is of great value in the treatment of all local inflammations, but which is not applicable in the case of pregnancy and lactation. Should suppuration occur, it is to be dealt with as an ordinary abscess ; but the gland not being in an active physiological condition is rarely the seat of suppuration. Ill pregnant or laetating^ i^omen. — In- flammation of the breast in the pregnant or puerperal woman is always a more serious afiection than when the same trouble affects a "woman diffei'ently situated ; for women in the conditions alluded to are ])articularly sensitive, and are open to impressions to which others, Chap. IV.] Treatment OF Inflammation. 39 wlio are neither pregnant nor lactating,are not exj)osecl. Intlamiuation, under these circumstances, attacks a ghmcl which is physiologically active, and conse- quently more prone to become the seat of inflamma- tion under the influence of any traumatism or dis- turbance of its functions. The earliest symptom of inflammation of a breast physiologically active is local induration with more or less pain ; and this induration indicates a lobular congestion of the gland ; indeed, this stage may be described as the "congestive." There will not be any redness, oedema of the skin, or constitutional distur- bance of any importance : gentle manipulation of the gland will not be resented. In the i:)regnant woman this "congestive" stage, if not due to injury, must be explained by some local disturbance to the evolution of the gland, giving rise to congestion of the vessels and blood stasis, which, if not relieved, will pass on to active inflamma- tion. To relieve it, the horizontal posture, as a means of helping the circulation through the breast, support of the gland by bandage, and gentle friction with pressure of the gland tov/ards its nipple, are of great value ; indeed, by these means alone, aided or not by some saline purgative, the symptoms will often subside and leave no mark behind. In the lactating woman, although the same treat- ment may be beneflcial, the surgeon should examine with care the condition of the nipples, to see if there is any obstruction to any of the ducts, or irritation about their orifices, and at the same time he should examine the lobules of the breast to see if any are choked with milk, in order that their distension may be relieved, either by- the manipulation already described or by some mechanical means. When suckling can be allowed, gentle friction in addition may be suflScient ; where this is impossible, some appliance for drawing 40 Diseases of the Breast. [Chap, iv off the milk should be carefully used. The breast pump I look upon with no favour, since I am con- vinced I have seen much harm follow its use by in- judicious hands. When it is employed, it must be used by the surgeon, and not left to a nurse, unless she be both skilful and judicious. Where the nurse is entrusted with the duty of drawing the breast, the least dangerous instrument is a tube with a mouth- piece for the nurse, or, indeed, the patient, to draw, fastened to a shield to press over the nipple, with or without a small reservoir between to hold the milk. The patient is hardly likely to hurt herself by suction, and the withdrawal of but a few drachms of milk from an over- distended lobule will give relief to pain, as well as to the congestion, and tend to check the inflammatory action. The application of pressure to the breast by means of strapping, at this stage of the trouble is often beneficial. The nipple should be left uncovered, as suckling may be useful. When there are external signs of inflammation such as redness ; or constitutional symptoms, such as pyrexia, to indicate true inflammatory action, the application of the lead and opium, or lead and bella- donna lotion, applied warm, gives great comfort and does good. The patient should under these circum- stances maintain the horizontal posture, and the breast should be carefully supported, either by cushions or bandages; one of the former placed between the arm and chest on the affected side is probably the most convenient. As the arm is not to be used, it is well therefore, at the same time, to bind it to the side with the cushion in position. Saline aperients are often of value, but they must be judiciously ordered, since they have a lowering tendency, and patients with inflamed breasts are rarely of the strongest build ; indeed, with them, as a rule, tonics are indicated, such as quinine, bark, Chap. IV.] Treatment OF Inflammation. 41 mineral acids, or even iron. Wlien the inflammation occurs towards the end of suckling this is always the case ; when it takes place in the early months, as a result of sore or malformed nipples in milk- ing mothers, purging is of great value. When the external symptoms of inflammation are marked, tlie constitutional symptoms acute, the powers of the patient good, and the causes of inflammation in the nipple have made suckling impossible, the local appli- cation of from twelve to twenty leeches is often of striking benefit ; they should not, however, be placed over the seat of redness, but near the margins of the gland on the affected side ; by this means the vessels supplying the gland are the better relieved. During the whole course of treatment the breast must be supported, and where pressure can be tolera- ted by means of strapping it should be applied. In every case of inflammation of the breast in a lactating woman, its probable cause should be made out, and treatment based upon it. When the action is due to retained secretion, the primary indications for relieving the congested breast of milk are clear ; and the secondary, for subduing the inflammation which is evidently the result of over-distension, are not doubt- ful. When it occurs towards the end of lactation, and is too probably the result of over-suckling, associated with general weakness of the body and want of power in tlie gland to do the work demanded of it, the in- dications are likewise clear ; to stop the cause of trouble by prohibiting suckling, and by medicine, food, and hygienic means to improve the condition of the patient, to enable her by natural power to arrest the disease. When the inflammation is brought about by retained secretion, active measures may be taken with a good prospect of success ; when from over-suckling and debility, the conditions under which the inflammatory action starts are most unfavourable, 42 Diseases of the Breast. [Chap. iv. since the subjects of tlie trouble, and the glands themselves, from over-nursing and exhaustion, show- little resistance to inflammatory changes, and time is wanted for the remedies to take effect. Under such circumstances suppuration is almost sure to ensue. TreatBiient of abscess of the toreast. — When suppuration has taken place in a breast, as else- where, the soundest surgical treatment is to evacuate the pent-up pus as soon as possible ; by so doing the extension of the trouble is prevented, much pain is saved, and the course of the affection is curtailed. The only exception to this rule is where the suppura- tion is subcutaneous and very limited, and where the surgeon cannot determine the right point for puncture. To leave a large subcutaneous abscess to break, is to allow large portions of skin to become undermined and consequently to die. To let a true intraglandu- lar abscess take its course and find its way to the surface, is to waste time, cause much needless pain to the patient, and postpone recovery, and the same may be said of the submammary abscess, for in it, if the abscess is left alone, there must of necessity be bur- rowing of matter in all directions, and as a result the formation of sinuses, and much unnecessary damage to the breast and parts around. When the abscess is opened, the incision into it should be free, and it should without exception be made in a line radiating from the nipple. By following this line the risks of interfering with the ducts of the gland, and of thus adding to the chances of the gland becoming useless, are greatly diminished, and a reasonable hope may be entertained even in the worst cases that the gland may subsequently be able to resume its functions. When the abscess has been opened, and it is to be assumed freely, so that its contents may readily es- cape, the abscess cavity should be irrigated with some antiseptic lotion, such as that of iodine, and the walls ciiap. IV.] Treatment of Abscess. 43 {)f the abscess allowed to collapse ; pressure should then be applied by means of stra{)ping to keep tlie walls of the abscess in apposition, and the breast sup- ported ; the line of incision should be kept uncovered, and carefully guarded by some antiseptic dressing, to prevent decomposition, such as strips of iodo- form gauze dipped in a mixture of terel)ene one part, olive oil three parts ; or carbolic oil one in eighty ; and a small sheet of Gamgee tissue, or a wad of absorbent cotton should be fixed over all to absorb the discharge. In some cases, when the pus drains from a deep cavity, a drainage tube may be employed. The incision into the abscess should always be so arranged as to assist the drainage of the abscess, and the cavity of the abscess should be washed daily with iodine water, or some other antiseptic solution, either of carbolic acid, 1 in 80, or boracic acid lotion, ten grains to the ounce. In a submammary abscess an incision should be made as soon as a diagnosis of abscess has been formed. The opening should also if possible be made at the lower or outer border of the breast, and a drainage tube introduced after the cavity has been well irri- gated. The breast should likewise be steadily fixed, by strapping and bandage, to the thorax, so that its movement may be prevented and the walls of the abscess kept firmly together. In some cases of sub- mammary abscess, or of sinuses following abscess, it is necessary, so as to got a good result, to prevent the movement of the pectoral muscle by binding the arm to the side. In a case already quoted the benefit of this treatment was well exemplified, but in the follow^ing it was more striking. Sinuses about breasts following deep-seated suj^mra- tion three and a ludf years previously^ in a young single woman. — Miss M. U., aged 23, consulted me in 1875 for sinuses which riddled both breasts, and likewise the submammary tisbues. They had existed on the 44 Diseases of the Breast. [Chap. iv. right side for three and a half years, and on the left for three years. They had followed acute in- flammation which had come on without any known cause. Every kind of treatment had been employed without success. I simply strapped up the breasts, leaving the orifices of the sinuses open, dressed the wounds with terebene oil, and bound the arms to the sides to prevent movement of the pectoral muscles. In one month the patient was well. Tonics are almost always required in all these cases, and of these quinine is the best. Iron when it can be borne is also of value. Good food, with stimu- lants carefully administered, and good air are likewise essential. When the abscess is quite local, and the general condition of the patient good, nursing may be continued so as to keep the breast free from fulness, although it is not to be recommended ; but when the suppuration involves more than a lobe, it must be forbidden as much for the infant's as for the mother's sake. When sinuses are left after supjDuration, they may generally be healed by the careful application of well-applied pressure by means of strapping to ensure immobility of the parts about them ; when they are of some standing, the injection, of a lotion of chloride of zinc of from o to 10 grains to the ounce is most beneficial ; when they are superficial they should be laid open, and treated as open wounds. AVhen milkjistulce are present, that is, when tlie sinuses foUowino- an abscess discharo-e milk, the same kind of treatment is to be adopted as has been just described for sinuses ; their cure is, however, always troublesome ; indeed, it is not to be looked for until the breast has ceased to be a secreting organ. When the milk has " dried up," the fistulas will probably heal up with it, but not before. The induration which is left after inflammation of Chap, v.] Chronic Abscess. 45 the breast will slowly subside as the health of the patient improves, and even after the most extensive suppuration there is a reasonable hope that the breast may so recover its normal condition as to allow of suckling in a later pregnancy. Should there be any maiformation, retraction, or disease of the nipple, this result is not however to be looked for, but under other circumstances it may be anticipated. To guard against congestion and inflammation of the breasts of pregnant women, who from local or general bodily condition cannot or ought not to nurse, pressure is by far the most reliable means. This may be applied directly after labour in the form of a chest bandage, or by means of strapping, well adjusted ; the pressure mechanically preventing the flow of blood into the breast which of necessity pre- cedes secretion. When the stage for pressure has passed, and that of tenderness and congestion reached, the local use of belladonna, diluted with equal parts of vaseline or glycerine, is of great value. Saline purgatives ad- ministered with discretion help towards the desired end. CHAPTER Y. CHRONIC ABSCESS OF THE BREAST. In a clinical exposition of diseases of the breast, it is clear that chronic abscess of the gland should be considered apart from the more acute forms of inflammation ; since examples of this afiection ditfer much from the more acute troubles in their clinical history and symptoms, and are frequently 46 Diseases of the Breast. [Chap. v. mistaken for new growths, sncli as cancer. Tliej are ■met with in women at all periods of life, and attack the single as frequently as the married, and the sterile as often as the prolific. They follow at times some blow or injury, and are occasionally associated with lactation. More frequently, however, they form with- out any known exciting cause, and are very insidious. The symptoms are much those of chronic lobular inflammation, although, if possible, less well marked. They are chiefly those which are attached to a local swelling, slowly and insidiously increasing with little or no marked pain. The sw^elling from the first seems to be part of the breast, and to involve it as an infil- tration. In the early stage no other symptoms exist. Later on, there may or may not be oedema and exter- nal signs of inflammation ; but these points will best be illustrated by cases. 1. Chronic abscess in the centre of the breast of a married childless ivoman folloicing a blow ; nipple re- tracted. — Sarah M., aged 25, a married childless woman, applied to me on December 31, 1863, for a swelling which occupied the centre of her left breast. It had been slowly coming, and had appeared soon after a blow, which she had sustained eight months previously. There had been little or no pain attending its forma- tion. When seen the breast was universally enlarged, and formed a flattened globular swelling, in the centre of which was a retracted nipple. The nipple before the swelling appeared had been quite natural. The tumour was very hard and slightly tender on manipu- lation. Xo sense of fluctuation could be detected in it. A needle was introduced into the swelling for diag- nostic purposes, and when pus exuded, a free incision was made into the gland, and several ounces of greenish pus evacuated. A speedy cure ensued. 2. Chronic abscess in the breast of a single ivoman, withretracted nipple, simulating cancer. — Ellen A. , aged Chap, v.] Chronic Abscess. 47 56, single, applied to me in 1865 for a swelling which involved the whole of the left breast, associated with a very retracted ni[)ple. The breast was very hard, and the trouble had been coming for seven months. Tiie axillary glands were normal. The case looked like one of cancer. In two weeks, however, some signs of fluctuation were felt, and on the introduction of a needle for diagnostic 23urposes, pus escaped. The abscess was, therefore, opened, and a cure ensued. The retraction of the nipple had been congenital. 3. CJironic abscess in the left hreast of a single inoman. — Jane E., aged 32, a. single woman, came to me in 1865, with a large abscess, the size of a cocoanut, in her left breast. It had been coming for five months without any known cause, and with hardly any other local symptom than swelling. I tapped it, and drew off sixteen ounces of pus. I then in- cised and drained it, when a rapid recovery ensued. 4. Chronic abscess in the centre of the breast, ivith re- tracted niioj)le, foUoioing irregnancy . — Mary R., aged 41, a married woman, the mother of nine children, all of which she suckled except the last, came under my care on August 25, 1864, with a large central indurated swelling, occupying the right breast, and a very re- tracted and depressed nipple. The swelling had been gradually coming for nine months during her preg- nancy, and during this time the nipple retracted. She was confined at the natural term, and did well. She did not wean the child. When seen the skin over the swelling was adherent to the gland, a week later it was somewhat redder than normal, and in two weeks some evidence of pointing was discovered near the nipple. An incision was consequently made dee})ly into the gland, evacuating pus, and a rapid recovery followed. 5. Chronic abscess in the breast, nnassociated with lactation, discharging through the nipple. — Harriet B., 48 Diseases of the Breast. [Chap. v. aged 40, the mother of four children^ the youngest being eleven years old, came to me in June, 1865, with an abscess in the centre of her right breast, which had appeared without any known cause about ten months previously, and had discharged from the nipple three weeks. The breast was large and tender, and pus flowed freely from the nijDple. Tonics were given, and pressure Avas applied to the breast by strapping. In one month all discharge ceased, and some thickening of the breast alone remained, which eventually subsided. 6. Chronic abscess in the breast of a married wo- man, aged 64, vntliout known cause. — Hannah K., aged 64, a married childless woman, consulted me on Oct. 14, 1859, for an abscess in her right breast, which had been discharging from the nipple, and also from an orifice below the areola for two weeks. A swelling had existed in the breast for about three months pre- viously. It began as a swelling that was not very painful, which slowly increased, and then discharged. It was cured by a free incision and drainage, aided by tonics. The case was thought to have been one of cancer, and on that account was sent to me. 7. Chronic abscess of the breast, of four months' standing, in a single ivoman, mistaken for cancer ; excision of gland ; recovery. — A. S., aged 50, a single woman, came into Guy's Hospital with a central tumour of the right breast, which had been coming painlessly for four months, and was associated with a retracted nipple. The skin over the breast was healthy, and the lymphatic glands were not enlarged. The surgeon under whom the case was admitted took it to be one of cancer, and consequently re- moved the breast. Its true nature was then dis- covered. 8. Abscess in the breast loith retraction of the nipple, puckering of the skin, and sioelling, m a single looman ; simulating cancer. — Leonore W., aged 39, a single Chap, v.] Chronic Abscess. 49 Avoman, came under my care on November 22, 1866, with a swelling the size of a large walnut in the upper part of the left breast, which had been coining for months, with a nipple which was completely retracted, and with the skin over the tumour puckered and rixed to the parts beneath. The swelling was hard, and situated in the gland itself. These symptoms sug- gested a carcinoma. On going into the history of the case, it was elicited that the nipple had been retracted from birth, and that the puckering and adhesion of the skin were due to the cicatrix of an old abscess which she had had twelve years pre- viously. In the course of a few weeks the tumour softened, and its true inflammatory nature was revealed. It was opened, irrigated, and cured. 9. Chronic abscess in the breast of a 'pregnant looman with retracted nipple, and enlarged axillary glands ; recovery. — Mrs. II. , aged 37, a married woman, Avith one child three years of age, came under my care, in May, 1867, with a swelling which occupied the centre of her left breast, of six weeks' standing, and which had come on without any known cause. The nipple for three weeks had been retracting, and when seen the axillary glands were enlarged. The skin over the breast was healthy, and manipulation gave rise to some pain ; no fluctuation could be felt in the swell- ing. The diagnosis of the case was obscure. A month later it came out that the woman was pregnant about three months. The tumour then enlarged, and was indistinctly fluctuating ; an exploratory puncture was consequently made into the swelling, and, as pus escaped, this was followed up by a free incision ; a good recovery ensued. 10. Chronic abscess involving the whole breast, ivith retracted nipple ; incision; recovery. — Eliza W., aged 34, came under m.y care on June 6, 1867, with a general infiltration and enlargement of her right breast, of nine E— 25 50 Diseases of the Breast. LChap. v. months' duration. The nipple was completely re- tracted, and the skin over the breast seemed to be fixed to the gland beneath ; to the eye the skin looked natural. The tumour indistinctly fluctuated. The swelling was said to have followed a blow. This woman had been confi.ned in October, 1865, and was suckling in September, 1866, when she received the blow. Tonics were given. Later on, fl.uctuation having become distinct, au incision was made into the centre of the gland, and pus evacuated, after which recovery took place. 11. Abscess in an inactive breast, loith retracted o'dpple; simulating cancer ; cured. — Ellen D., aged 39, a married woman, the mother of three children, the youngest being eight years of age, came under my care on April 1, 1867, with a swelling in the axillary lobe of her lef fc breast, and a retracted nipple ; the base of the nipple being drawn towards the axilla. The swell- ing had been gradually coming for three or four months without any known cause, and was the seat of a sharp pain. It was vaguel}^ globular and doubtfully elastic. The axillary glands were sound. Its true nature was uncertain, and for diagnostic purposes an incision was suggested, but consent for this was not bbtained. In two weeks the skin had become glued to the parts beneath, and some slight redness appeared ; an inci- sion was consequently made into the breast, and some ounces of pus evacuated. In three weeks the patient was well. 12. Chronic enlargement of the breast ivith retracted nipple, simulating cancer, chronic abscess 2 excisions- cure. — Mrs. W., aged 64, consulted me in November, 1875, for some enlargement of her right breast, which had been coming on for about four months. The nipple was retracted, but this condition was said to have been congenital. There had been but little pain in the breast during its enlargement. AVhen I saw her the Chap, v.] Chronic Abscess. 51 breast was generally enlarged and indurated. Tlio nipple was completely retracted. The skin over the breast was natural, and there were no enlarged axillary glands. I regarded the case as one of carcinoma, and advised excision. The operation was performed, and a rapid recovery ensued. The patient, now nearly twelve years after the operation, is quite well. On making a section of the gland through the nipple after its removal, a quantity of yellow purulent fluid escaped and scattered itself over everything. It had been ejected from a cystic cavity, which occupied the centre of the gland, and the walls of the cavity looked as if they had broken down. With the naked eye exami- nation I was in doubt as to the cavity being caused by a softened cancerous tumour, or to an abscess. Dr. Goodhart consequently examined the growth, and reported as follows : " 1 have examined the breast tumour you sent to me. Without venturing to be too positive, I think it is only inflammatory ; at any rate, all the appearances Diet with are explicable on that hyjoothesis. The breast tissue is still quite distinct and healthy looking, but in places a large number of granulation-like cells are found crowded into the fibrous tissue, normal to the part. There is no variety of shape, and no excess or easy disjdacement (milky juice) of cellular ele- ments. Outside the breast tissue proper the fat is undergoing definite change, not that of infiltration, but of absorption of oil, and crystallisation of marga- rine, etc., leaving behind cells which at first look suspicious from their size, but which, I believe, are nothing more than fat cells gone into training, and having disposed of their superfluous oil. " The naked eye appearances are quite those of a chronic inflammatory tumour; healthy breast swollen out, in fact, not infiltrated. " I shall be glad to know any result that may 52 Diseases of the Breast. [Chap. v. hereafter declare itself, and in. tlie meantime shall believe that it will not recur." 13. Tumour in the breast of a 7)iarried 'prolific icoman, tweheyears supposed to have been a cancer, which suppurated and ivas cured. — In March, 1860, a married woman, aged 40, the mother of six children, whom she had suckled, the youngest being eight months, was ad- mitted into Guy's Hospital under the care of the late Mr. Hilton, with a tumour the size of an egg in her right breast, which had been steadily growing for twelve years. It was clearly in the gland, irregularly nodular and hard. The skin over it was glued to the tumour beneath. The nipple was natural, axillary glands free. The tumour first appeared twelve years before, when the woman was twent^'-eight, and had increased after each confinement and period of lacta- tion. It was supposed to have been carcinoma. Whilst under observation, however, it inflamed, and discharged healthy pus. A free incision was subse- quently made into it, and a rapid recovery followed. This tumour could hardly have been an inflammatory one from the first. - It might have been at the begin- ning a galactocele or cyst which subsequently suppu- rated. When the notes of the case were taken by me in 1860, no reasonable explanation of the case could be found. These cases, which are well worth studying, and on that account have been reported, are enough to indicate the difi'erent courses a chronic abscess may take ; the different symptoms to which it may give rise ; the difficulties that may be experienced in form- ing a true diagnosis ; and lastly, the errors of treat- ment that may be made. They are enough to teach the surgeon the neces- sity of caution both in forming an opinion, and in dealing with the case when the diagnosis is not sure. They indicate the propriety of making an exploratory Chap, v.] InFLAMMA TION IN THE MaLE BrEAST. 53 puncture or incision into any tumour whenever there may be the slightest doubt as to its nature, a lesson which the consideration of tumours themselves will help to enforce. Inflainiiiation aiiSg a.ted thoracic _disea_se ; under suchcircumstances, tlie breast trouble is a consecutive one, and needs no discussion. When it appears as a local affection, these tumours are slow in their progress, and rarely ' attain any size larger than a walnut. They make their appearance as often as not without any known cause, but occasionally after injury ; they are fre- quently multiple. They occur in delicate lax young women under 35, who suffer from catamenial irregu- larity, and are at times the seat of jDain of a lanci- nating character: usually this is very slight, and the pain is intermittent. Dr. Leger writes on the same subject, and reports * a case of a pale anaemic single lady, aged 30, wlio, seven months before consultation, discovered an indurated lump the size of a filbert at the lower part of her right breast. This nodule steadily increased * Bull. Soc. Med. d' Amiens, 1878. Chap. VII.] Scrofulous Breast. 65 in size, and when seen was knotted, subdivided into lumps, and at the same time painful. The skin over the lump was slightly adherent and of a violet colour. The nipple was somewjiat retracted ; axillary glands free from enlargement. The lady had chest symp- toms and night sweats, and she died from phthisis. Billroth reports the case which he described as one of chronic caseous matter, producing mastitis in a scrofulous girl, who was brought to him with nodules containing caseous matter, varying in size from a hazel to a walnut, in her breast. Each one was incised, and then cauterised with nitrate of silver with a good result. Richet describes * a case, in which, at the outer part of a breast, a tumour the size of a turkey's egg existed, made up of three parts, which was elastic, and hard ; pus flowed from two incisions which had been made into it. When pressure was made upon the tumour, pus no longer flowed, but there exuded a sort of plastic lymph, yellowish, stringy, not resem- bling the foetid discharge of cancerous tumours, but recalling rather the appearance of thickened lymph. Richet adds, that tuberculous or caseous tumours of the breast, alone, have the characteristics as above described. Other cases of this affection are on record, and I am sure I have seen some, but have failed to re- cognise them at the time as I ought. My attention was drawn to the subject by an able paper published in Gaillard's Medical Journal of New York, June 1884, and written by Dr. G. Durant of New York, who after a careful review of the whole subject, sums up as follows : ^ From a clinical point of view, tubercles of the '^' breast present two varieties, perfectly distinct from each other: (1) a disseminated form; and (2) a con-,^" fluent form. In either, the onset is insidious; the * Gdzctte dcs Hdpitaux, May 13, 1880. F— 25 66 Diseases of the Breast. [Chap. vii tabereular matter is developed slowly, and without producing pain, and some time elapses, usually, before tlie patient becomes aware of any trouble in the breastu Sometiines, but very rarely, even at this period, one or more enlarged lymphatic glands, under the inferior border of the pectoralis major may be found. They vary in size from that of an almond to that of a hen's egg ; they suppurate, and a fistula remains, from which a serous pus, containing caseous clots, exudes. These openings, after existiag for several months, may seemingly heal, but with the progress of the disease in the substance of the gland they re- open and again discharge. In the disseminated form either there is no increase in the volume of the breast, or it is so slight as not to attract attention. The skin is not adherent to the anterior surface of the breast, the nipple retains its nsual pouting form, and the mamma moves readily on the underlying tissues. Careful pjolpation detects hard masses in the substance of the gland. These are disconnected, variable in number, and the size seemingly inversely as their number. Usually they have the size of an almond, biit may attain to that of a wahiTit. They have but little mohilitij, seeming to be connected wdth the adjacent tissues. Their snrfaca is roughened by gi^anulations, their con- sistence is firm, though not cartilaginous. Seldom do they give rise to pain. They develop veiy slowly, and often after they reach a certain size the growth ceases. In one case no increase in. volume could be perceived, though four years had elapsed between the examinations. The termination of this fonn is un- known. Dubar "^ says that he is unable, from his re- searches, to say whether they may disappear spon- taneously in whole or in part; or whether, a subacute abscess being formed, they may thus be eliminated. * " Tubercules de la Mamelle." 18S1. Chap. VII.] Scrofulous Breast. 67 The confluent form. — While the disseminated form may remain latent during the lifetime of the patient, and only be recognised at the autopsy, this is not true of the other variety. The tubercles by their acjcrlomeration and fusion constitute tumours, which, on account of their increasing volume, cannot long remain hidden. The breast may in a few days y double in volume from a sprouting out of one or more of these nodules. All these changes may take / place without inflammation and without pain ; while in other cases, febrile symptoms, gastric disturbance.s, and severe pain, press hard upon ' a .sick one. The pain may be continuous and lancinating, or it may continue several days, then disappear, then return anew. Palpation tells us that the growth is not equally distributed throughout the organ. It is con- fined to one portion of the gland, and here an ovoid body of uneven surface and variable size may be cir- cumscribed. Almost immovable in the substance of the gland itself, with which it seems connected, the tumour does not appear to send prolongations back- wards. It is unyielding to the touchy and yet, by fixing the mamma by one hand, a sensation of flue- -^ ^l^J:li2SL_£lSJ_^6-__P6rceived. In that portion of a gland where the new gi^owth is not so well developed, only a diff'used swelling exists. The lobulation of the gland can with dii3iculty be recognised ; the skin is normal, is readily moved over the anterior surface of the organ, which itself is not abnormally adherent to the deeper parts. Should a puncture or in- cision be made into one of the fluctuating points, a varying quantity of a purulent liquid, containing caseous clots, will escape, and the volume of the breast will diminish. After a var^'ing time (a month and a half in one case) the fistulous openings close and a sHght pufiiness alone remains. Sooner or later, however, the swelling reappears, and a new incision 68 Diseases of the Breast. [Chap. vii. is made, or an opening appears, which remains permanently. When the tistulse are well established, the disease has reached its full development, and the appearance of the gland is characteristic. In that part of the breast greatest in size a well-defined- tumour exists, and on a level with it one or more fistulous openings. At the anterior wall of the axilla, fistulas with fungous ridges are found in the centres of circumscribed tumefactions. The skin around these openings is a dusky red, and for a slight dis- tance is adherent to the subjacent parts. The nipple may be retracted should the fistulous opening be in its neighbourhood. Behind the fistula, palpation reveals more or less extensive induration. At the axilla the fistulse are not deep, while in the mamma the probe may penetrate from one to two inches. The exploration is not painful, nor does noticeable bleeding follow. The tissue exposed through the opening is found to be very soft and friable. One would suppose that this ever-extending, though slow growth, would sooner or later destroy the whole organ. It is not impossible, however, that a portion of the breast may be spared. The termination of tubercu- losis of the mamma by natural process is unknown. Probably a deposit in some other organ, as the lung, terminates the scene. Dr. Durant draws the following conclusions : (1) That the breasts may be the seat of tumours similar to the pathological products found in many other organs, to which the name of tubercle is given. (2) Tubercle in the mammary gland is much more common than is generally supposed. (3) That mis- takes as to the true nature of these growths have often been made, and ablation of the breast, from a belief in their cancerous nature, has often resulted. (4) That during life we may by clinical observation dis- tinguish them from other tumours. (5) That as no Chap. VIII.] Svp III Line Mastitis. 69 absolute necessity for the ablation of these tumours exists, we shoukl refrain from operating, unless un- equivocal siiifns of malignancy develop. With all these conclusions, except the last, I am disposed to agree, but would suggest that in the well- marked examples of this afiection it would be well to remove the gland, as by Dr. Durant's showing " the termination of tuberculosis of the mamma without intervention is unknown," and all pathologists are now convinced that persistent suppuration in any tuber- cular disease is prone to prove a centre for geneial infection, and that as a consequence the sooner it is removed the better. CHAPTER YIII. SYPHILITIC MASTITIS. This affection is one which should be recognised, al- though it is far from common. I have seen but few examples of it. Why it should be so rare may be difficult to explain ; it is probable that such cases have been mistaken for and treated as examples of cancer. Neither John Hunter, Sir A. Cooper, Brodie, Birkett, nor Gross, mention the affection. Lancereaux, in his treatise on Syphilis, tells us that the celebrated Sauvages * gave an excellent example of it. The case occurred in an unmarried woman, aged 30, who had been using, for several months, the ex- tract of hyoscyamus. She presented, in each breast, a tumour the size of a hen's ^g%. Dense and knobby, this tumour caused lancinating pains, which extended at times as far as the axillary region, along a chain of * "NosolosiaMethodica." 1768. 70 D:iEASES OF THE B RE A ST. Xhap. VIII. glands equally hard and knobhy. The patient had nlcers in the mouth and vagina, resulting from syphiHs acquii-ed ten years before. Keyser's pills, continued for a month, caused the disappearance of the painful tumours, and other syphilitic manifesta- tions, which did not return. Pdchet* says, " This tumour presents itself at fii*st with all the characters of a scirrhous tumour, and I confess that in a case observed at the Lourcine Hos- pital, extirpation was on the point of being performed when the discovery of another tumour, if not similar, at least analogous, in the calf of the leg, induced us to wait. The simultaneous disappearance of these two tumours under an appropriate treatment completely removed all doubt.'"' Ambrosoht relates three cases, one in a male, two in young women, aged 19 and 24 respectively. Both of the latter presented, soon after the disappearance of syphilitic exanthema, a diffused, firm, somewhat painful swelling of the breast, Avithout change of colour of the skin. This swelling being associated with induration of the axillary glands, iodide of potas- sium, in large doses, effected the removal of these symptoms without leaving any trace of their exist- ence. "I have," said Lancereaux, in quoting this case, "seen a very similar one." Teipeau, in his work on "Disease of the Breast," as translated by Henry, 1853, mentions four cases, as observed by Maisonneuve, and one by Pvichet. One was a simple gummy tumour. In three others there was at the same time ulcei-ation of the skin over the tumour, and circumscribed congestion of the mam- mary gland. In all, there existed at the same time other syphilitic manifestations, such as gummatous tumours on the head, ulcers on the legs. The cure * " Traite d'Anatomie Chirurgicale. " 1857. t GazOta Medica Lorabarda, Xo. 36 ; ISGI. Chap. VIII.] Syphilitic Mastitis. 71 in all was rapidly brought about by preparations of iodine. Studied in both sexes, syphilitic lesions of the breast differ in no way from those of other organs ; they are most analogous to those of the testicle. They are essentially gummatous infiltrations of the connective tissue, covering the breast, behind it or in one or more of its lobules. In exceptional cases the whole gland may be involved. The disease, where it attacks the subcutaneous tissue over the gland, will show itself as an ordinary gumma, and run its course in the same way. When it affects a lobe or more of the breast, its clinical symptoms are obscure. It may appear as a more or less defined tumour in one lobe, of which it seems to form a part, and the skin over the tumour will in this stage of the affection be natural. As the lump increases, the same want of other symptoms will be experienced, and the tumour may yet feel hard, and be painless. The skin over it may yet be free. The axillary glands may, however, be enlarged. Should the swelling form in the periphery of the gland, the nipple will be natural ; should it do so near the centre of the gland, there may be retraction of the nipple. As the disease progresses, the tumour will enlarge, and the skin over it will become involved, but as in a chronic inflammation, and not as in a scirrhus ; it will become glued first to the parts beneath, then be- come of a dusky colour, later on, red, and last of all ulcerated ; not first dimpled, then puckered, and sub- sequently infiltrated as in cancer. The tumour also, as these superficial changes appear, will become more fleshy, softer, and at last give rise to the feeling of fluctuation. In this, its last stage, the disease has either par- tially or wholly softened down, and may discharge itself as an abscess, or the whole tumour may die as a 72 Diseases of the Breast. [Chap. viii. mass, and slough out as may a bursa, tliickened and inflamed hj gummatous inflammation. The progressive softening of a gumma in "whatever gland or tissue it may be found, is a characteristic symptom of the affection; for diagnostic purposes it consequently requires emphasis. This disease, although slow in its progress at jfirst, is more rapid towards its close. It mostly attacks women under thirty, although it may appear in a syphilitic at any time. Bumstead states thatrb^niay occur as a result of hereditary syphilis, and I am disposedTTo agree'with him7~siiiceTr~have seen an example of disease of the testicles from this cause, and the two diseases are analogous. It can hardly be mistaken for cancer in its later stages. In its early stage the error may take place. The age of the patient in which it occurs, the presence of other manifestations of syphilis, the clini- cal history of the case, and above all, the suspicion that tl^e disease may be gummatous, will be the best help in diagnosis. GuiuDiatous infiltration of hr east ; slougliing of the y}hole gland. — Martha C., a married woriian, aged 46, who has had no children or miscarriage, came to me on August 12, 1869, with an infiltration of the upper lobe of her left breast, which had been coming for eight or ten months. The skin over the swelling was natural. She had with this, enlargement of the axillary glands, and a su})purating node over her left frontal bone, which had been coming for six months. There was no pain in the tumour. Tonics with iodide of potassium, in increasing and full doses, were given with benefit. On October 25, 1869, the breast tumour had be- come bossy, and presented the external features of inflammation, such as heat and redness, with fluctua- tion. On March 31 the breast had greatly enlarged, and was as large as a cocoanut. The skin over it was ulcerating, and the gland tissue through the opening Chap. IX.] Tumours. 73 looked dead, and presented the yellow wasli-leather aspect, so characteristic of syphilitic deposit. In Sep- tember, 1870, the whole mass sloughed out and fell as a putrid mass into a basin, leaving a clean granu- lating surface. On November 10 the woman was well. No history of syphilis could be obtained, but the case was doubtless a true gummatous infiltration of the Ijreast, as supported by the presence of the suppurating frontal node. The prognosis in tLis affection is favourable so far as the life of the patient is concerned, and probably so as far as the gland itself is considered, should the diagnosis of its true nature be made out in its early stage. A gumma of the breast ought to be as amenable to treatment by the iodides of sodium, potassium, or ammonium, as a gumma of any other part. These drugs should be given in steadily increasing doses, up to a drachm or more a day. In exceptional cases the removal of the breast by opera- tion may be justifiable. I have, however, never been called upon to perform such an operation. Constitutional treatment in by far the majority of cases may be expected to bring about a cure. CHAPTER IX. TUMOURS OF THE BREAST. Tumours of the breast may rationally be accounted for by following out the functional aberrations of the organ, and in proof of this we may all with advantage study carefully the highly suggestive and valuable work of Dr. Charles Creighton, on the "Physiology and ■74 Diseases uf the Breast. [Chap. ix. Pathology of the Breast" (1878), who has shown that "the investigation of breast tumours reveals merely the working of the physiological law of healthy mammary activity under altered circumstances^ that various degrees of disordered function may result in various kinds of tumours," and that tumour disease of the breast is " essentially a disorder of function." The breast, in passing from its "resting" or inactive state to that of full activity, undergoes during the entire period of pregnancy a process of " evolution " which is characterised in its different stages by certain cell changes within its acini, and transpoi't of cells without; and, in the return of the gland to its quiescent condition on the subsidence of lactation, a process of " involution " in which a parallel series of changes acting in an inverse order is to be observed, the functional subsidence of the gland being spread over a shorter period of time than its gradual awakening during pregnancy. When the functional stimulus of the mamma is acting at its loicest point at the beginning of " evolu- tion" or the ending of "involution," the secretory pro- ducts are larg;e _ pi'anular y ^low_pao-me_iii ed cells, which are found wmim the secreting acini, in the connective tissue spaces outside the secreting structure, and like- wise in the lymph sinuses of the subjacent lymphatic glands, these cells being the waste products of a feeble degree of secretory activity ; and, if the mammary ex- citation were always to act at that degree of intensity^ the secretion, it may be said, would always be in the form of large granular pigmented cells. At the next ajypreciable advance in the intensity of the stimulus, the product formed in the gland may be described somewhat generally as a large granular nuclear cell, which is nothing else than the crude epi- thelium of the middle period of the breast's unfolding in which an imperfect secretory force resides. Chap. IX.] Tumours. 75 Coming still nearer to the full excitation, the cellular ingredients are fewer and the mucous production much more abundant ; and finally, when the stimulus is at its height, the mucous fluid has given place to a fatty fluid, and whatever cellular elements the secre- tion contains are the well-known colostrum cells which approach most nearly the perfect secreting cell. The periodical unfolding of the breasts, which is an obvious accompaniment of each pregnancy, is thus characterised by a progressive series of immature seci-etory products which necessarily run to waste. The epithelial cells are not transformed into milk till the time of delivery and during the period of suckling following ; but the functional action of the breast has been at work all through the pregnancy, and has advanced in intensity just as the secreting structure has advanced in its unfolding. The various stages of unfolding have corresponding secretory products, be- coming less and less crude, and as there is a similar series of more rapid but exactly parallel waste pro- ducts in the upfoldiiig, it is a legitimate inference to ascribe " a special kind of secretory product to a cer- tain degree of intensity of the glandular force." When the breast gland is disturbed from its resting state by a cause other than pregnancy, and in conse- quence of some morbid excitation is urged into a kind of evolution process, the steps of its unfolding are less orderly than in the normal evolution, and the " spurious excitation " never cai-ries the gland to the end of its unfolding, or to the perfect degree of its function. And although the morbid excitation may be said to correspond in its intensity to a stage of the normal evolution, there is this fundamental difference, that the corresponding stage of the normal process is transient, giving place to a stronger force, while the morbid process continues indefinitely at the same en- feebled level. As a consequence, the cell that should 76 Diseases of the Breast. [Chap. ix. have been thrown off from the acinus as waste almost as soon as it was formed, remains in the j)lace of its origin to multiply, and, with its progeny, to infest the glandular structure of the breast either as intra or extra-acinous accumulations. Indeed, according to Dr. Creighton, it is upon deviations from the physio- logical track such as these that the existence of a tumour depends. Thus, "a circumscribed tumour arises at a particular part of the gland where the spurious excitation has advanced to a certain stage of evolution or unfolding; in that particular region, probably a territory defined by the blood-vessels, the functional force has acted at a uniform imperfect level for a length of time, the inevitable cellular waste of the crude secretion has ac- cumulated within the acini or around them, and the foundation of a tumour has been laid. In the healthy action of the organ there is a pro- vision for the disposal of the v^ery considerable amount of cellular waste material by means of the neighbour- ing lymphatic glands. In passing from the secreting acini and in tra^^ersing the stroma of the gland, the waste cells often acquire a spindle form ; and although these cells are not always distinguishable from the connective tissue cells of the part, there is, especially in the bitch, a class of pigmented epithelial cells in which such changes of form and position can be clearly traced. The spindle-shaped waste products are the type of the peri-acinous cell collections in cystic or adeno-sarcoma. So far as relates to the large nuclear cells, the in^z-tt-acinous collections of them corresj^ond to the structure of medullary cancer, and the e^^r«-acinous infiltrations of the same cells are a distinguishing feature of scii^hus. " The distinguishing feature of the less malignant form of tumour is that the spurious funztional activity comes nearer in the degree of its Chap IX.] Tumours. 77 intensity to that of the perfect secretory force, tlio ti'ansformation of the epithelium is a more real trans- formation, and the cellular waste is reduced, in part at least, to the class of fibre-like or crescentic elem(?nts that characterise the myxomatous and more benign issues of the tumour process." " The circumstance that the unknown diseased excitation most commonly befalls the gland when it is in the state of rest is of the first importance in ac- counting for the formation of a tumour. Whether the disturbance be a mechanical injury, or a sympathy with excitememt in the ovaries, or of a more general emotional nature, it comes upon the breast in its rest- ing state. The breast can react in no other way than by following the somewhat slow process of its normal evolution ; without the intermediate stages of unfold- ing it cannot reach the perfect degree of its functions in which there would be immunity from danger. The intermediate stages are necessarily associated with the formation of crude cellular products ; it is at one or other of the intermediate stages that the morbid force delays, and the corresponding cellular secretion of the gland thereupon assumes the character of a foimitive or tumour process." " The circumstances of the functional disturbance are never exactly the same in any two cases, conse- quently the respective modifications of structure, or in other words, the structure of the respective tumours, is never exactly the same." " It is the climacteric effacement of the breast that gives a peculiar character to the disease in women, and there are well-marked structural differences in the tumours according as they appear before or after that period. Those that develop after the climacteric years are perhaps the most common, as they are cer- tainly the most intractable, and they have been the real source of ambiguity in the patliology of the oi'gau. 78 Diseases of the Breast. [Chap. ix. That ambiguity depends upon the circumstance that they occur in an organ which is gradually losing or has lost its cliaracteristic structure." Where the normal itself is vanishing, the departures from the normal are elusive. It seems probable, therefore, from Dr. Creighton's investigation, that the fibromata, adenomata, sarcomata, myxomata, and carcinomata of the breast have their type in a series of progTessive changes which the gland undergoes in its physiological evolution. The feebler the intensity of the Jun ction, tlie^ Qore_cancerousJ;he disease; the higher_OT more advanced the evolution from the resting^state^he more_ benign the tumour. Under these circumsl:ances, there is difficulty in making any definite classification of breast tumours ; indeed, if we take the pathological anatomy of diseases of the breast, it is practically impossible to adopt any classification that is precise, which does not involve the writer of a systematic monograph on the subject in much repetition. The breast, it must be remembered, is composed of a skeleton of connective tissue and furniture of gland cells, and there is no single class of breast tumours which may not for any individual case (scirrhous carcinoma excepted) show the free participation of both these elements. As one or the other pre- dominates in any individual tumourj so will it be called sarcoma or adenoma, according to the proA^ailing opinion of the day, although practically all the cases are essentially of the same complex structure. Furthermore, any tumour in a tubular gland must almost of necessity be liable to the formation of cysts • its very structure presupposes it. Thus all tumours of the breast more or less are associated with cystsj some largely so. Neither the presence of a cyst in a breast tumour, nor of many cysts, has, however, much pathological meaning, although in a clinical sense it so Chap. IX.] Tumours. 79 happens that in a certain group of breast tumours which are largely and chiefly cystic, the term cysto-sarcoma has been applied. For the great majority of breast tumours it is therefore true that in any one of them there may be, at the same time, connective tissue, gland acini and the derivative of gland tissue, viz. cysts. Some, and these chiefly foreign observers, have classed most tumours which are not carcinomatous with the sarcomata, on the ground that histological investigation shows that the connective tissue is the initially aggressive element, but it is probably a sounder and at any rate it is a more universally applicable view to regard the type of breast tumour as a composite one, and therefore it seems expedient to retain the old term adenoma for many of them, since to call all these tumours sarcomata is to place them in a group which prevents one from saying positively that any individual case is free from the risk of recurrence, when clinical experience teaches us in no uncertain way that the solid adeno-sarcomata of young women are for the most part free from any such risk, and that a large number of the cystic tumours are equally benign. On the other hand, there is not one of them, be it myxoma, fibroma, or sarcoma, which may not return should it develop under the faulty inhibition of later life. I cannot, therefore, agree, as I should wish to do, with the view of that excellent surgeon. Dr. S. W. Gross, of America, as expressed in his recent work upon the Breast (1880), and draw a fast and clear line between these varieties of tumours ; indeed, I would rather, after the fullest consideration of the subject, still prefer* to maintain the word ade^ noma as indicating the special gland elements in most of the varieties of neoplasm of the breast, adding the word fibroma to the more fibrous form ; the compound word, '■^ adeno-tibroma," clearly expressing 8o Diseases of the Breast. [Chap. ix. the pathology of the class of tumours as well as its clinical peculiarities. The word will therefore be thus used in this work. On this matter I will, however, let Gross speak for himself : " While it is true," he writes, " that hyperplasia of the glandular tissue of the breast may be so excessive as to constitute the tumour known as adenoma, this occurrence is so rare that true ade- nomata must be ranked among the most infrequent of neoplasms." " In all of the connective tissue tumours, the lacteal glands, although their epithe- lium may be in a state of irritation, generally remain passive, and as the growth advances they may disappear to such an extent as to be scarcely, if at all, recognisable. Instead, therefore, of being newly formed and predominant, the secreting elements are really merely accessory or accidental, and represent the remains of old or pre-existing glands, contained, but widely separated, in a fibromatous, sarcomatous, or myxomatous stroma" (p. 304). I should like, moreover, to add that the diagnosis between any of the varieties of breast tumours not carcinomatous is uncertain and difficult, and whether a tumour is to be called a fibroma,- adeno-fibroma, adenoma or adeno-sarcoma, can only in the majority of cases be determined by a histological examination of the gi'owth after removal. Clinically I would therefore still divide breast tumours into two great classes, the carcinomatous, and the non-carcinomatous dividing the latter large class into the adeno- fibromata, adeno- sarcomata, and cysto-sarcomata. Under these headings the different tumours will therefore be considered. I shall treat of the carci- nomata by themselves, and likewise all the cystic tumours, with or without intracystic growths ; the lipo- mata, chondromata, and colloid tumours receiving their share of attention. r -L /: . . /, 'k&kK - 0» 8i CHAPTER X ADENOMATA AND ADENO-FIBROMATA : THE FIBROMATA OF GLANDS (a SARCOMATOUS ENCAPSULED GROWTH). Under the term adenoma without doubt a large va- liety of tumours of the breast have been grouped, this word having included "sarcomatous tumours" of every variety ; the " chronic mammary tumour " of Sir A. Cooper ; the " mammary glandular tumour " of Sir J. Paget; the " tumeur adenoide" of Yelpeau; the "corps fibreux " of Lebert, and the " adenocele " of Birkett. At the present day this grouping is not recognised, consequently, to place myself in accord with its teaching, I shall in the present volume de- scribe several groups of tumours of the breast. The " fibromata " and " adenomata " of the breast may, in a pathological point of view, be kept distinct, yet it is not possible clinically to maintain this dis- tinction ; since in bedside work it is beyond the power of the surgeon to diagnose with any certainty the one variety of growth from the other ; and it is only by a microscopical examination of any indi\ddual tumour after its removal that its true pathological position can be made out. It is well, therefore, to know that such a definite diagnosis is of no practical importance, and that the treatment of these varieties of tumours is the same. Indeed, in a pathological sense there is no great difference between the glandular and connective tissue groups, since all are made up of connective fibrous tissue, ducts, acini, and the csecal terminations of the ducts in varying proportions. The growths, G— 25 82 Diseases of the Breast. [Chap x. as a 'v\-liole, form a cliain, of Trliioh the links at one end are composed of fibrous tumours, in wliicli the fibrous elements predominate ; and at the other end of adenoid tumours composed of more or less typical glandular elements, and containing even glandular secretion ; whilst tlie intermediate links represent tumours of a mixed tibro-adenoid type. A connective tissue tumour, which in non-glandular structures would be either a fibroma, sarcoma, or myxoma, when found in a gland, which is normally made up of gland structui^e and connective tissue, becomes mixed up with the glandular elements in very variable degrees, so that in the breast where these varieties are best seen we have adeno-tibroma and adeno-sarcoma. Whilst the special characteristics of the tumour may be determined by the changes which are found in the connective tissue of the gland, the changes in the glandular elements themselves are not to be ignored or passed by as of no significance, since I hold it is due to the presence of these gland elements, and the changes that take place in theDi in morbid processes, that the pathology of breast tumours difiers from the pathology of tumours of the ordinary connective tissue unconnected with the gland structures. It must be remembered that a gland is a compound structure composed of connective and fibrous tissue, with the special gland element in the form of cell structure. In the breast this gland structure is tubular with clusters of CEecal acini lined with epithe- lium appended to the tubes. The breast glands, moreover, are subject to periodical excitement, and at times to active secretion. Under these circumstances, though in variable de- grees, increased nutriment is sent to them, and with it increased physiological force is supplied. Should this force fail to attain its true physiological outlet and secrete milk, or should it from some outside or inward Chap, X] Benign Tumours. 83 cause be excited at wrong times, and as a morbid condition, it will probably tend to mischief, and in a clinical point of view this mischief will, as a rule, take the shape of a new growth. When an unnatural or morbid excitation affects any part of the gland, and as a consequence growth appears, the result may be overgrowth of any one or of all the elements of which the gland is composed ; under such circumstances the gland as well as the connective tissue structures will increase, and give rise to either the adeno-fibroma where the fibrous tissue is in excess, to the adeno-sarcoma where the cell structure predominates. In the early history of gland life, the force which the part has supplied to it, in common with the other regions of the body, is registered in growth and development. At a particular period, again, in its existence, partly, no doubt, owing to calls that are made upon it, and partly, also, to a tendency long inherited to take on a definite action at a definite time, the gland leaves off growth and takes on the capability of secretion, and thus is provided an outlet for its energy. Supposing now that, in the full tide of this developmental activity and high nutrition, a part of its secreting surface becomes shut off, or injured and excited when its dormant power cannot find equilibrium in secretion, what more likely (if, indeed, it be not just what we should expect) than that it should go back to its prior forma- tive processes, and commence again to grow % Is not this physiologically sound % At any rate, presumptive evidence in its favour is afforded by the fact that these adeno-fibromatous, cystic, solid, and adenomatous tumours are most common in young unmarried women; in other words, in those in whom secretion is in a state of nascent activity. Give this no outlet, and new growth will very possibly result ; but, more 84 Diseases of the Breast. [Chap.x. than this, the new growth is likely to be of such a kind as shall be a fair index of developmental tone, and of an otherwise healthy state, viz. a fair substitu- tion for healthy gland structure. That this is true is demonstrated by the fact that in certain adenomatous tumours of the breast, encapsuled as ordinary fibro- mata, the new structure may secrete the normal secretion of the breast. The two following cases taken from Mr. Birkett's experience demonstrate the fact. They have been published in the Guy's Hospital Reports for 1855. ^'■Case 1. Adenoma with duds and secretion, — E. A. K., a healthy married woman, when 2 1 years of age, and a fevi^ weeks after marriage, in 1850, discovered a small lump in her left breast. It was situated in the axillary region of the organ, and she is quite sure it never entirely dispersed. I saw her for the first time in January, 1852. She gave birth to her first child in January, 1851, which she suckled, and mostly with the affected breast, until October, when the infant died. At the time I saw her she was pregnant with her second child, and the condition of the left breast was as follows : it was very heavy, solid, and I thought I could detect fluctuation. It was about double the size of the right breast, and the enlarge- ment seemed chiefly in the axillary region of the organ. The external appearance was simply that of inordinate size and fulness, globular, and projecting from the thorax. The nipple was displaced consider- ably, and although never well developed, took a direction forwards, inwards towards the middle line of the body, and upwards. Scarcely any pain was ever experienced in the part, but only an uncomfort- able sensation of weight. Doubtless, the fact of her being in advanced pregnancy gave rise to considerable difliculty in arriving at an accurate diagnostication of the disease, for it was not until after parturition, Chap. X.] Benign Tumours. 85 in April, 1852, that a new growth could be distinctly felt. The second child she suckled some months. A third child was born in December, 1853. This she suckled one month, and then it died. Whilst suckling the second infant, milk abscesses formed consecutively in the left breast, which obliged her during the later months of lactation to suckle with the right gland only. For several months previous to the operation for the removal of the tumour, its nature was very clear. During the later months of suckling, and after weaning, the normal gland being relaxed and flaccid, the firm solid new growth could be grasped by the hand, and isolated from the breast. At the same time the skin rolled freely over the tumour, and the lobulated surface of the growth was distinctly traceable beneath it. A very large vein was also seen travers- ing the surface of the tumour, and during lactation the dimensions of this vein were enormous. It took a course towards the axilla, where it was lost. On the 28th of February, 1854, I removed the tumour by merely dividing the skin over it ; the mass being only very loosely connected with the gland, not a lobe of the true breast was cut, but it was left entirely in its normal situation after the tumour which displaced it was detached. The tumour weighed three pounds. Yery little haemorrhage followed the incisions ; the edges were adjusted by means of plaister, and the wound healed in about a month. The tumour was composed of lobes loosely connected together. Each lobe could be separated into lobules; these again into glandules or acini, which contained the ca?cal terminations of the ducts. From these the smaller ducts united to form larger, and they traversed in some places the interlobular spaces. The free ends of some of these ducts terminated loosely on the surface of a cyst, which contained a large collection of a soft solid material, resembling thick cream. An analysis of 86 Diseases of the Breast. [Chap.x. tliis compound, made by Dr. Odling, aflbrded the following results : Fat .. 85-31 Water .. 11-43 Albuminous matter, casein r... .. 1-63 Animal extractive •21 Inorganic matter ... •58 " Besides this large collection of cream in a rather thin- walled cyst, there was not far distant from it, of smaller size, another cyst, filled with an almost cre- taceous material. The wall of this smaller cyst was firm and rigid, or like a piece of thick parchment. " Case 2. — The only case, except the last described, in which I have found ducts containing milk, was shown to me by Mr. Nathaniel Ward, who removed it from a patient in the London Hospital. The follow- ing are the particulars of the case : "E. D., an unmarried and healthy girl, when 23 years of age, discovered a lump in her left breast, about three and a half years before she showed it to Mr. Ward. The catamenia did not appear until she was nineteen years of age, then they ceased for nearly a year, and when they again reappeared, the general enlargement of the breast commenced. For a few months before the removal of the tumour, a well-de- fined and lobed mass, connected with the gland, was perceptible. It was situated behind those lobes of the gland which form its sterno-cla^icular quarter ; but with care the normal gland tissue could be dis- tinctly detected, independently of the tumour. The lobes of the tumour were clearly visible beneath the skin, and a large vein traversed its surface. It was removed in May, 1855, by Mr, Ward, without any of the breast, and that gentleman sent me a section of the new growth. It was one of the firmest, most dense, and closely packed, small-lobed tumours, which ciK.p. X.J Benign Tumours, 87 I have examined. It had an extremely irroguLir external surface, and between the lobes or in the interlobular spaces, which were united together by loose filamentous tissue, were some large veins. These could be traced into furrows between the irregulari- ties on the surface of the tumour. Ducts were also distinctly seen taking a course directly transverse to the large veins, and apparently disposed upon the surface of the lobes and between them, without any very definite arrangement. Many of these ducts contained secretion exactly resembling cream. The follicular terminations of the ducts were very per- fectly developed, and were very minute, although not so small as those of the normal gland tissue. No juice pervaded the mass, but in some places this creamy secretion of the ducts was easily expressed by the cut surface. " The mammary glands, the nipple, and areola, were in this instance remarkably characteristic of the virgin state. It is, therefore, a most singular fact that a new growth should possess the function of a normal gland, although somewhat imperfectly, espe- cially when those organs, which the new growth closely resembled, had never been stimulated to the performance of their own peculiar function. " We shall now take a comparative review of these two very interesting cases : Both the patients were very young women, in good health, when the tumours were first observed. One had been mar- ried, and was in the earl}'- months of pregnancy when she discovered the tumour. The other was an unmarried woman, and a virgin, when the development of the tumour began. In both cases soon after the observation of the tumour, con- siderable difficulty arose in diagnosticating the dis- ease ; in the first case, on account of the general enlari>ement of the mammary gland coincident with 88 Diseases of the Breast. [Chap. x. pregnancy ; in the second, because the development of the new growth was accompanied with general enlargement of the entire organ. Until this general enlargement of the organ had subsided, the tumour was not perceptible or distinguishable by touch or sight. When, however, in one case, lactation had produced a rather relaxed state of the breast, and, in the other case, the general excitation of the organ had subsided, then, and not till then, the diagnostica- tion of the disease was comparatively easy. " There remarks are introduced in order to show the very great caution which should be exercised in pronouncing an opinion upon the nature of almost all diseases of the breast during any active or excited condition of the normal mammary gland. Surprise would perhaps scarcely be excited by the existence of the solid and fatty particles of milk, in the case in which the function of lactation had been performed upon three separate occasions while the tumour was srrowinsf. But the other case demonstrates that even a virgin may have a tumour of this nature developed in the breast, and that the new growth may so closely resemble the normal gland, and be so perfectly well developed, as to secrete the fatty and oily particles of common milk. "In both these cases the tumours were removed without cutting away the smallest piece of the normal mammary gland, a proceeding highly important in a practical point of view ; indeed, in all cases of a like kind, the breast itself should be carefully sought for and preserved. This important fact is alluded to by Sir Benjamin Brodie." At times these breast growths are composed of loosely connected fibre tissue, with but a small ad- mixture of the glandular elements ; the growth would then be called fibro-cellular. The best example of this kind that I have seen I now record. The Chap. X.] Benign Tumours. 89 clinical history of these cases, however, and the chances of complete immunity from future trouble after the removal of the primary growth, are the same as in the most benign tumour. Fihro-cellular tumour of breast, weighing, on removal, four pounds thirteen ounces. It had com- menced during pregnancy, and had grown rapidly during lactation. It was removed, and a good recovery took place, the woman being well fifteen years subse- quently. Louise H., aged 34, a married woman, the mother of five children, came under my care on March 17, 1868, with a tumour in her left breast, which had been growing for eight months, and had made its appearance during the sixth month of pregnancy. She had been confined when coming under observa- tion five months, and was suckling with the healthy breast, but not with the affected one, although at times milk ran from the nipple. The tumour, during three months, had grown rapidly. When seen the left breast formed a large tumour, which measured twenty-five inches in circumference, and at its base seven inches. It was quite movable over the pectoral muscle, and the skin over it, though stretched, was not adherent. The nipple was flattened out. The surface of the tumour was somewhat nodulated, and the mass felt solid and elastic, but it did not fluctuate. The temperature of the breast was higher than the healthy gland. The axillary glands were not en- larged. The tumour was excised, and weighed on removal nearly five pounds.* " Under the micro- scope the tumour was found to be composed of fibro-cellular structure in various stages of develop- ment. A certain portion was made up of wavy tissue fully formed. A larger portion was composed of elon- gated cells, and fibre cells splitting up into bundles * Guy's Hosp. Mus., Prep. 229')'^5. go Diseases of the Breast. ichap. x. of wavy tissue, and in this structure a large number of nuclei were observed. In addition to tbese ele- ments, simple cell structures were observed in various portions of the tumour. These cells were for the most part closely packed together, so that in a section composed chiefly of wavy tissue and fibre cells, here and there an accumulation of simple spherical cells could be seen." * It seems that on rare occasions these growths may appear in infancy ; when so, they are not to be ex- pected to show the complete glandular elements of adult life ; on the contrary, they show more of ele- mentary structures, such as the fatty and fibrous, with some tubes. In the following example these points are illustrated, the best glandular elements of the case being the presence of tubes. Lipomatous adeno- fibroma in the breast of a male child ten months old ; oi:)eration ; cure. — Absalom S., aged 10 months, was admitted into Guy's on July 20, 1874, under the care of my late colleague, Mr. Cooper Forster, with a hard tumour, the size of a walnut, situated above and to the outer side of the left nipple, which moved freely upon the deeper parts, biit to which the skin was adherent, but not dis- coloured. The mother had noticed the lump for about four months, and it had grown rapidly. The growth was excised on July 22nd, and found to be made up of fat and fibrous tissue, with some imperfectly developed breast tubes. " The tumour showed a number of tubes like breast tubes, and outside them a germinating fibrous stroma, containiug oval nuclei " (Goodhart). The child did well. Macroscopical appearances of the ade- nomata and adeno-fitoromata.— The external physical characters of these growths after removal, * Committee on Morbid Growth.. Path. Soc. Trans., vol. xix. p. ciiap. X.] Benign Tumours. 91 as well as the appearances of their surfaces on section, are very variable, and yet in both aspects they possess a strong family likeness. That is, all are enca'psided, although the capsules may vary much in their density ; all are lobulated, some but slightly, others in a verv marked bossy way (Plate I. Fig. 1). All have, on manipulation, a firm and fleshy fed ; and they rarely, if ever, are so hard as a scirrhus. Some of these tumours, although a small minority, are intimately connected with the breast, so that to remove them, a portion of the gland itself will have to be taken away. Others, which form the large majority, are so loosely attached to it, that they may be shelled out, on the division of the capsule which surrounds them. In a few cases the tumour is pedunculated and appears as a kind of outgrowth from the edge or one of the surfaces of the gland. On section, the cut surface of every variety of these two forms of tumour has a tendency to become convex, and to exude a tenacious mucoid fluid. It has, when fresh, a white, pinkish or red appearance, ac- cording to its vascularity, and presents many difierent forms of lobulation, as well as degrees of density. Jn some cases the surface will show either a coarse or fine fibrous structure, and under such circum- stances, little or no glandular elements will be found ; the tumour belonging to the fibromata. Whilst in others the most striking feature will be that of lobu- lation. It occasionally happens that these two varie- ties of tumour are found in the same breast. In examining a series of specimens of this kind, the varieties of forms which the lobules assume is very remarkable. Where the lobules are large, the growth will generally be succulent ; when they are small, it will be compact. In the compact form the microscopi- cal structure of the tumour will be that of a fibroma, 92 Diseases of the Breast. rchap. x. including in its concentric interlacunar bundles of fibrous tissue the caecal terminations of the ducts and acini of the gland. In the more succulent forms of growth the tumour will be more or less furrowed and fissured, foliated or dendritic, and ducts in the process of development wdll be seen mixed with the true glandular elements. In some cases, Fig. 2.— Section of an Adenoma, or Adeno-fibroma of the Breast. again, the lobules will be compact, smooth, and appa- rently homogeneous; whilst in others, or even in another part of the same tumour, the lobe will be subdi^ided up, and each small lobule will be appa- rently, except at its base, free from connective tissue attachments to the neighbouring lobules (Fig. 2). Under these circumstances, it will present to the eye much the appearance of a coarse papillomatous growth pressed into a capsule, each papilla being composed of the csecal terminations of gland structure, filled Chap, x.] Benign Tumours, 93 Avitli epithelial cells, and held together by fibrous elements. Histologically the epithelial elements will be normally arranged (typical) upon their special base- ment membrane, and although these elements may be found in excess within the acini of the gland struc- ture, they will still possess a kind of regularity in their arrangement. In carcinoma no such regularity will be observed. The epithelial gland elements will not only have no special relation to the cell wall, but they will be found in as great abundance outside as within the cell, and irregularly placed. In fact, they will be found to be infiltrating the whole structure. The j)resence of the membrana propria in adenoma, and its absence in carcinoma, differentiates the one disease from the other. In many of these tumours, rounded cavities or irregularly curved spaces are visible, which contain a mucoid fluid, possibly more or less blood-stained. These spaces are sometimes dilated ducts, containing degenerating epithelium, and sometimes apparently spaces due to the distension caused by the degenerate products of the epithelium of the growth. In certain examples of the solid lobulated adeno-fibroma occupy- ing one of the lobes of the gland, and associated with it, cysts will be found of all sizes, more or less occupy- ing portions of the gland. The cysts may be present without as well as with intracystic growths, and these growths may be of different dimensions and of different structure. Such growths will, however, to a certainty ap- proach the adenomata in microscopical structure, and show a very variable amount of connective tissue elements between the lobules, some being dense, others very loosely connected, indeed, probably floating in the serous fluid of the cavity (duct %) in which it is growing. 94 Diseases of the Breast. [Chap. x. The co-existence of these varieties of growths in the same gland, at the same time, raises the question as to the origin of the more solid forms, and suggests the probability that they had originally an intracystic origin, and had filled the cyst. This pro-, bability is likewise supported by the clinical fact, that in these cases of solid growth there is occasionally found during their development a serous or san- guineous discharge from the nipple, which can be increased by pressure; and also by the pathological facts that in certain specimens* a tube can be intro- duced into the duct near the nipple, and from it all the cysts composing the mass of cystic and intracystic growths inflated ; while in certain cases in which, after removal, fresh growths appear, the first tumour will be of the more solid or fibrous variety : the second in time of age, cj'stic with loose intra- cystic growths; and the third like the first,f solid. The first and last gTOwths being adeno-fibromata, the second cystic adenoma. The following case of Mr. Birkett's illustrates this point : Of the alternation of the so-called " chronic r}iammarjf'^ tumour, and the '''■ cysto-sarcoma'" in the same individual, and at different i^eriods of life. A healthy, married, but sterile woman, was first seen by me in June, 1851. She was forty-five years old, strong, and in good health, although lately she had felt weak and sinking, and had become rather thinner. The catamenia were not regular, and at times she had sufi'ered with dysmenorrhoea. Four or five months before her application to me she discovered a lump in her right breast ; it had been preceded by a pricking and shooting pain, and these sensations had attracted her attention to the part. When I saw the tumour it measured about one and a half inches square; it was * Guy's Hosp. Mus., Prep. 229335. t Guy's Hosp. Mus., Prep. 2299^^ and ^^, and a drawing 402-'3. Cliap. X.] JJexicn 2'L'MOUKS. 95 seated on the surface of the gland, and rather towards its sternal border. It was very firm, movable, lobed, and irregular on its surface, and it seemed quite, de- tached from the tissues of the breast itself. The woman suffered great pain upon gentle manipulation, and even for some time afterwards. The nipple was unafiected and the axillary lymphatic glands were quite healthy. She said her sister had died of a cancer in the face. Her general health at this time was a little deranged, her appetite bad, and she complained of weakness. Soothing applications were employed over the tumour, and her general health being im- proved by the exhibition of medicines, the tumour was removed on the 16th December, 1851, by making a single vertical incision through the integuments. No part of the breast itself was removed. The new growth was enclosed in a loosely attached envelope ; it consisted of three unequally proportioned lobes, and these of lobules which were all associated together by loose connective tissue, in which the c?ecal ter- minations of the ducts loaded with epithelium were enclosed, constituted the lobules. The wound healed favourably, although the whole gland was extremely tender and swollen, soon after the operation. During the whole year 1852 the breast was usually painful at the catamenial periods, and there appeared to be considerable local excitement in the organ. In November, 1853, two years after the first operation, a new growth was discovered near the cicatrix ; the whole breast was very painful ; and in February, 1854, I removed this second growth, together with the cicatrix and a very little adherent gland tissue. The dissection of this new growth ex- posed several cysts of variable size, and which were filled with iiTtracys t,ic gro^v ihs^mi nutely and j jielydiyided into lobules : these were very loosely united togetherby 96 Diseases of the Breast. [Chap. x. connective fibre tissue. In another part was a growth much more resembling in apj)earance the first growth that I removed ; it was firm, lobulated, enveloped in a fibrous capsule, and entii'ely united into a solid mass by connective fibre tissue. As in the first growth, so in these, the minute elements of gland tissue were dis- tinctly visible when magnified ; and although the csecal terminations of the ducts difi"ered from those of the first growth in many jDarticulars, yet they were well marked and characteristic. The vround healed favourably, but during the summer months of 1854 she suflered great pain in the axillary half of the organ ; the whole became much swollen and indurated, and resembled the breast of a woman during the later months of pregnancy. In October, 1854, I discovered a third growth at some distance from the cicatrix, and among the axillary lobes of the gland. This increased rapidly, and was accompanied with general swelling and induration of the breast. I removed the third growth in February, 1855. It was much larger than either of the others, was embedded in the lobes of the breast, and was firm, dense, lobulated, and united together by connective fibre tissue. In this growth the csecal terminations of gland tissue were distinctly seen. In July, 1855, the patient was well. The principal facts of the case are as follows : The patient when the first growth was discovered, was 45 years old. The first growth was eleven months old when removed ; between the removal of the first growth and the discovery of the second, one year and ten months elapsed ; the second growth was three months old when removed ; between the removal of the second growth and the discovery of the third, eight months elajDsed ; the third growth was four months old when removed. All the growths, varying as they did in their external apjDearances, still exliibited, when Chap. X.] Benign Tumours. 97 carefully :ind minutely examined, those elements and structui-es which are found in the mammary gland itself, with the exception of ducts. All, therefore, come under the denomination " adenocele." The first and last were, however, of the same nature as the tumour termed by Sir A. Cooper, " chronic mammary tumour." The second growth \ belongs to that class of groAvths described by many /' ^ writers under the term " cyaJtiizsarcoiaa." / This case, therefore, clearly demonstrates, that in one and the same individual, at different times, these new growths may alternate with each other. It likewise shows, that the second growth_grew jnoj-e ^' rapidly tlian_tlie tirst, and the third more rapidly than eMier of the other two ; and also, that the interval of time between the development of the second and third growth was much shorter than that between the lirst and second. These facts, which repeat them- selves in the natural history of recurrent new growths, are now generally recognised. Such cases as these form as it were connecting links between the more solid varieties of fibromata and fibro-adenomata, and the cystic forms of benign breast disease, to which attention will be drawn in the chapter devoted to the subject of "cystic disease with intracystic growths." When these fibro-adenomata are undergoing de- generating changes, they will appear to the eye of a yellow colour, and by pressure or scraping the cut surface, cheesy dead epithelial cells may be made prominent, tinder other circumstances, when the growth is undergoing a myxomatous degeneration a section of the growth will present a honey-combed surface, and the hollows of the fibrous structure will be tilled with a gelatinous mucoid fluid. Syiiaptoms. — These benign solid tumours of the breast are usually discovered by accident, the patient's 98 Diseases of the Breast. [Chap. x. attention being rarely drawn to the part by anything that could be called pain ; an uneasy sensation in the breast is the most that is experienced. Such a tumour feels, when discovered, as a hard or fleshy,, smooth or lobulated nodule, upon, behind, or within the substance of the breast gland; it is generally very movable, and feels like a loose body in the breast, which may at times be separated from it ; but should the growth occupy the centre of the gland or one of its lobes, this separation will not be possible. As it grows, it troubles mainly from mechanical causes, for it maintains its original fea- tures throughout ; it may develop fresh lobules, or become more rounded in its outline, but it will never do more to surrounding structures than stretch tliem, or press them aside. The mammary gland itself, when these growths are large, may become atrophied, or pressed away up to one or other side of the new gTO%vth, according to the lobule of the breast in which the growth originally appeared. When the tumour is central or approaches that position, the breast will be flattened out over its suiface. The nipiDle is rarely much influenced by the growth, and when so it is from mechanical causes. Thus a tumour occupying the centre of a lobe covered with breast structure will stretch the ducts, draw upon the nipple, and thus cause either an obliquity of its position, or some retraction (Fig. 4, page 177). Should the tumour be a central one, and press equally in all directions, the nipple will become either flat or retracted ; I have seen several examples of this aflection in which this latter condition was present. Fain. — Very little pain attends the growth of tliese tumours ; indeed, in the majority of cases the only sources of bodily discomfort of which patients complain are due to the mechanical eff"ects of the tumour. The chief distress is mental, viz. the fear ciiap. X.] Benign Tumours. 99 of what seems so simple becoming eventually a "cancer," or a source of unknown and severe trouble unless submitted to operation. In exceptional cases pain is, however, experienced. Mr. Birkett men- tions the fact that in one case intense sufi'ering was due to the filament of a nerve being included in the new growth ; and I have certainly found the breasts of some young women who have these growths as sensitive as the simple and uncomplicated irritable mamma. The integument covering the growth is very rarely implicated, since it is elastic, and yields kindly under a distension which is sIoav and steady. Should the growth, however, be rapid, the skin may inflame, and even ulcerate, so as to allow the escape of the tumour's contents. With solid growths such as we are now considering, this result is very rare ; I have but once known inflammation to occur from distension in such a case. In cystic disease the complication is more common. These tumours never become fixed to the deeper tissues, and only affect them mechanically by pressure, although, as I have said, they may be found to be adherent to adjacent portions of the breast. They do not as a rule give rise to any lymphatic enlargement, and should they do so, it will probably be from some degenerative or necrotic change which is taking place in the growth, or from some iiri- tating effect the growth is producing on the skin or parts around. When lymphatic enlargement co-exists with a tumour which is believed to be benign, the suspicion of its being otherwise should be raised. Rapidity of grovi'tli.— The more solid the tumour, the slower its growth ; the more succulent and loose the structure, the more rapid its increase. When associated with cysts, a tumour may enlarge rapidly, and this enlargement may be the product of increased loo Diseases of the Breast. [Chap. x. effusion, or due to the occurrence of bleeding into the cyst. I have recorded a marked example of the latter cause in the twelfth volume of the Pathological Society's Transactions. On the other hand, these tumours on rare occasions cease to grow or even diminish in size; .when it is probable that the diminution in size is due to the absorption of some of the fluid that bathed the free portion of a pedunculated growth. I have been quite u*hable to determine the average rate of increase of these tumours ; it is so variable. The fibromata and more solid adeno- fibromata rarely attain any size ; one the size of a large walnut may be the product of three or four years' growth, and another three inches across repre- sent the gTowth of fifteen or more years. The more succulent varieties of the adeno-fibromata, although they are usually larger than the more solid, attain a great size in only rare examples. I have removed one of the compact form from a married woman, aged 30, four inches across, that was said to have grown in as many months. In exceptional cases both the solid and succulent varieties may grow rapidly. The cystic forms, as will be shown later on^ niay, however, increase up to the weight of many pounds. A tumour that grows rapidly with the clinical features of an adeno-fibroma, and is not cystic, is probably sarcomatous. Multiplicity of aod recurrent gi'O^vths.— It is by no means rare for the breast of a woman to hold two or more of these adeno-fibromatous tumours, and both breasts at times may be equally affected. When more than one exists in the same breast, the tumours are as a rule of the same form and density, but I have on more than one occasion removed from a breast a compact tumour, which would be patho- logically described as a fibroma, and at the same time Chap. X.] Benign Tumours. ioi a second tumour of a looser and more succulent kind, made up of glandular elements, to which the term adenoma would be applicable : the former example containing but little, and the latter much, of the glandular structure. In the same way, recurrent growths may vary in individual character, though agreeing in kind; a primary growth may thus be of the compact kind, and the recurrent of the succulent ; in Prep. 2299^^ of the Guy's Hospital Museum there are three specimens demonstrating this, the third par- taking of the characters of the first. Wliat has been described as recurrence in any given case may be, in truth, simply the continued growth of a tumour which was overlooked during the first operation on account of its smallness. I have twice seen a second small fibro-adenoma come into view in the incision for the removal or the first growth, which, had it been undiscovered, would have grown, and been called, though wrongly, a recurrent tumour. Tumours that re-appear a few months after the removal of the first growth should be regarded as growths that had not been discovered. {See pages 108, 109.) These '■'' adeiw-fihromata" are found as a rule in the young and unmarried, and in the apparently healthy and robust ; they occur, however, occasionally in the aged. The best example of the kind T have seen was in a single lady, aged 71, and it had been of twelve years' growth. When I saw iier it was ulcerating. I consequently removed the whole tumour and gland, with an excellent result. The specimen contains sam- ples of every variety of this class of tumours ; some masses rejjresenting well the fibronia, others the most typical and marked adenoma, both of the compact and loose forms. The adeno-fibromata are seen in every stage. The more compact form of adeno-fibroma, or fibroma, appears genei'ally in girls about the age of puberty, the gland structure at this age having but I02 Diseases of the Breast. [Chap. x. just adranced sufficiently far so as to be ready under the natural stimulant of conception for a more com- plete development. In such subjects, when the breast is the seat of a new growth, the adenomatous element is slight, but the fibrous is in excess. In maturer women, and specially in those who have borne children or nursed (when the procreative organs are active, and the mammary glands are in a state of "developmental perfection'') the most perfect ex- amjole of adenomatous tumour is to be expected, since in these subjects the glands have reached their hio-hest physiological function, and consequently their highest development, and any new growths originat- ing in connective tissue at this period would naturally include the active gland structure, and present a more or less succulent and well-marked adenoma or adeno- iibroma, the gland elements being in excess over the fibrous. They are occasionally met with in men in the proportion of 1 to 277 cases of adeno-tibromata in women, as shown by Mr. W. R. Williams, in an able analysis of 11,100 cases of neoplasms admitted into four large metropolitan hospitals, during periods varying from ten to seventeen years, and ending 1883. In women the majority of these cases begin to grow, or are first discovered, between the ages of 21 and 30, although, as shown by my table, almost as many begin in younger people, at or after puberty ; at later periods of life they less frequently originate, although they may be frequently found to exist in them. From my notes of 100 cases consecutively observed, seen, and analysed to make out these points, 27 cases were first discovered between puberty and the ao-e of 20, that is, dimngthe developmental stage of the breast's life. 85 cases appeared between 21 and 30 years of age, or during the period of its functional perfection. Chap. X.] Benign Tumours. 103 22 cases appeared between 31 and 40, duiing the perjod of its maturity. 13 cases appeared during 41 and 50 ; and 3 cases appeared in women over 50, or during the period of its functional decline. 46 of these cases occurred in single women; 39 in the married and prolilic ; 15 in the married and sterile. Single women during their prime are consequently most prone to be attacked by these growths, and the married and prolitic are the next ; the old maid and the married and sterile woman being comparatively free from these benign tumours. Cause. — No dehnite cause can usually be ascribed for the appearance of these growths, althougli in quite exceptional cases injury has been assigned. I cannot say, however, that I have ever been satisfied v\^ith any such explanation, for the tumour has usually been discovered too soon after the supposed cause to render the suggestion probable. As a rule^, indeed, these tumours are discovered by chance, some accident or blow having drawn the patient's attention to the part, and thus led to the disclosure of the tumour. ]>iag:uog!S. — This should not be a difficult task in the majority of cases. A fleshy or firm movable lobulated tumour in the breast of a healthy looking single or married woman under thirty ; with a mam- mary gland, its nipple and skin covering, in other respects apparently healthy ; and with a history of the slow and probably painless increase of the new growth, or if painful, only so at intervals, or at the times of the catamenial flow, is probably an adeno - fibroma. The more movable it is in the gland, the greater the probability of this diagnosis being correct ; the more fixed it is, the greater the chance of the tumour being sarcomatous Any growth that infiltrates the gland, wholly or in part, I04 Diseases of the Breast. [Chap. x. must be inflammatory or cancerous. The absence of fluctuation in any part of the tumour, and the absence of a marked lobulated or botryoidal out- line, excludes polycystic disease ; although in every case of growth believed to be benign found in the breast of a woman over thirty, the suspicion of its being cystic should be entertained. The solid or non-cystic fibro-adenomata grow, as already described, in capsules, and simply expand the tissues in whicli they are placed ; they do not spread, as the cancers do, by either local, lymphatic, or vascular infection, but cause trouble simply mechanically by their pre- sence ; they do not give rise to discharge from the nipple, as do many of the cystic tumours, and they are generally found in women who are apparently healthy. Prognaosis. — This is, as a rule, favourable, for when one of these tumours has been removed there is every reason to believe that no return will take place. When a second growth appears soon after the re- moval of the first, there is good reason to believe that it is but the continued growth of a neoplasm which existed undiscovered at the time of the first operation ; for I have on two occasions at least, when an adeno- fibroma was being removed from a breast by an in- cision through the breast gland, which covered the capsule of the neoplasm, seen exposed a small en- capsuled second growth, about the size of a pea, which, if left at that time, would have grown, and appeared as a second or return growth. (Second or third growths are, however, met with, but such, as a rule, originate in other lobes than that primarily in- volved, and cannot consequently be called recurrent, for such a term refers to the re-appearance of a neo- plasm in the position of some antecedent growth, which I do not believe takes place in one out of a hundred cases. Many of these tumours after a time cease to grow, or do so but very slowly ; some without Chap. X.] Benign Tumours. 105 doubt cliininish in size, and when tliis diminution takes place, the growth is i)robably cystic, and the; X* absor})tion of the fluid about the growth has causetl its apparent shrinkage. To this point attention will be drawn later on. {See Shrinkage of tumours, page 344.) The more fibrous and glandular, or adenoid, the growth is, the better the prognosis. The more em- bryonic and cellular the connective tissue elements (that is, the more the growth approaches an adeno- sarcoma and deviates from an adeno-fibroma) the greater the probability of a return. Treatment.— As a general rule all these tumours should be removed by excision, since experience tells us that they will continue to grow with variable degrees of rapidity ; that a tumour which has taken months or years to attain a certain size may often double itself in as many weeks or months, and that no local treatment by applications and no medicines have the slightest influence in retarding their develop- ment or helping their disappearance. It is not, however, necessary to remove every tumour of this kind as soon as it is discovered, for it may grow so slowly, and be so little in the way, as to render its removal a matter of small urgency ; at the same time, such a tumour should be taken away from any woman who is likely to become pregnant, or who is past the age of 35 ; since with a pregnancy the neoplasm is certain to gi-ow, as it, with the gland itself, will have increase of blood sent to it, and likewise from nerve causes will receive an im- pulse towards growth ; and after the age of 35 adeno-fibromatous growths are more likely to pass on to the adeno-sarcomatous, which are far more dangerous. The operation itself is neither a difficult nor dangerous one. It usually consists of a clean incision through the overlying tissues into the capsule and io6 Diseases of the Breast. [Chap. x. then the subsequent enucleation of the growth. The tumour should be well pressed forwards by the left hand of the surgeon grasping the tissues deeply on each side of the tumour so as to make it prominent and the tissues over it tense ; the incision into the capsule of the growth should always be free> and made in a line radiating from the nipple, as by this incision there is less harm done to the breast structure which surrounds the growth, and the risks of in- juring the milk ducts are much diminished. When the capsule has been divided, the growth will pro- bably become partly extruded, and its complete ex- trusion will be facilitated by the division of any fascia which appears to hold it back, and by introduc- ing the handle of the knife between the capsule and the growth so as to lever it out of its bed. The attachments of the neoplasm to its capsule are at times very slight, and under these circumstances it is readily enucleated ; when the attachments are stronger or broader, they may want division with the knife, and under these conditions some vessels may require to be twisted or otherwise secured. In exceptional cases the neoplasm is so closely connected with the breast tissue as to necessitate the removal of the lobe of the gland in which it is placed. All bleeding should be thoroughly arrested before the wound is closed, by the torsion of every vessel of any size, and the temporary introduction into the cap- sule or cavity of the wound of a sponge wrung out of hot iodine water. Its edges should then be carefully adjusted by means of fine sutures and strapping, and the wound dressed, a provision being carefully made for its drainage for twenty-four hours. A little gentle pressure, applied either through iodoform gauze, salicylate wool, or a soft sponge rendered aseptic with iodoform or boracic acid, and bound on with a Chap, x.i Benign Tumours. T07 bandage, is most useful in checking capillary oozing and venous luemorrliage. In the majority of these cases the wound heals by quick or primary union ; where this vvished-for result is not secured, the cavity must be daily washed out with iodine water, or some other antiseptic wash, well drained, and carefully dressed with such antiseptic dressings as are favoured by the surgecm. Breasts, after having been subjected to an operation for the removal of one of these benign neoplasms are rarely so injured as to prevent their performing their physiological functions when occasion calls. In the larger forms of tumour and of operation this result may ensue ; but when the neoplasm is of moderate dimensions it is not to be anticipated. Should the tumour have been allowed to attain a ] large size, it may be impossible to separate breast v gland from growth ; under such circumstances it may 1 be necessary and expedient to excise both. It must, \ however, be stated that large tumours, even up to seven pounds, may be removed from a gland, and the latter left intact and capable of performing its true functions ; and under these circumstances it is the surgeon's duty to attempt to save the gland, even when it may appear hopeless. These principles of practice are clearly applicable to cases met with during the child-bearing period of life. At later periods the object for retaining the breast does not exist, conse- quently the practice based upon it is not necessary. To render the scar of the operation as invisible as possible, Gaillard Thomas, of New liork,* when the tumour is of moderate dimensions, makes his incision in the fold which unites the lower hemisphere of the breast to the thorax, and having dissected the gland from its deep attachments, removes the tumour by an incision made in the under surface of the breast. The * New Y(yrlc Med. Journ., p. 337 ; April, 1882. io8 Diseases of the Breast. [Chap. x. wound is then carefully drained and treated, and tlie subsequent scar is very limited. It occasionally happens that a breast which has been the seat of an adeno-fibroma becomes, in later years, the subject of a cancer. The secondary neo- plasm must be regarded as a new growth altogether, and as having only a very slight connection with the first, that connection being probably the same as exists between a cancer and a scar in other })arts. To more fully illustrate many of the practical points mentioned in these pages, the following brief notes of cases, extracted from my note-book, will be read with interest. The first case refers to the fact that in making a sec- tion of breast tissue to enucleate an adeno-fibromatous growth, a second smaller tumour was exposed. 1. Adenofihroma of breast; excision ; second tumour discovered by the incision tnade to remove the fi^rst ; re- moval of second ; recovery. — Harriet P., aged 30, single, a servant, came under my care on September 23, 1874, for tumour in her left breast. It had ajDpeared nine months previously as a small movable lump, which steadily increased. At present it measures three inches by two, is situated below the nipple, is movable, nodulated, and firm. On the 25th an incision was made over the tumour, in a line radiating from the nipple, into its capsule, and the growth enucleated. When this was done, a second tumour was discovered placed deeply in the gland beneath the one that had been removed. ' This was then enucleated, and a good recovery followed. A precisely similar case to this came under my care in the person of Sarah V., aged 25, in March, 1882. The second case illustrates a very important point in the life history of an adeno-fibromatous or other tumour; and that is, the enlargement of lymphatic glands, and their subsequent subsidence after the Chap. X.] Benign Tumours, 109 removal of the primary growth. The case is likewise an example of multiple tumours. 2. Two adeno-Jibromata in one breast, with enlarged lymphatic gland ; subsidence of loiter after removal of tumour. — Sophy S., aged 30, a childless married woman, came to me on May 19, 1850, with two hard lobulated tumours on the axillary half of the left breast, which had been growing for three years. One was as large as a walnut, the second as a nut. Both moved freely in the breast. There was also an enlarged lymphatic gland in the axilla. May 28. The tumours were enucleated through one incision, and were excellent specimens of the adeno-fibromata ; the gland elements predominating. The patient made a good recovery after the operation. The enlarged lymphatic gland disappeared. This patient was quite well four years later. The third case is an example of double tumour in a breast, the two tumours being good examples of two of the varieties of adenoma. It shows, moreover, the effects of pregnancy upon the growths, and the value of saving the breast in the operation. 3. Adenoma of breast, associated with adeno- fibroma, complicated with pregnancy ; suckling with the affected gland; operation; recovery. — Frances F., aged 22, cauie under my care March 15, 1869, with a large tumour in her left breast of two years' standing, and a smaller one of twelve months'. She was then six months pi'egnant. During the pregnancy the tumours grew fast, as they did during lactation, which she carried on with the affected breast, after a natural labour, for three months, when she weaned the infant. On November 7 one tumour was as large as a cocoa- nut, and the second the size of a small orange. The latter tumour was much harder than the former. On January 3, 1870, I removed the tumours and left the breast intact. no Diseases of the Breast. tchap. x. The larger tumour, as seen in Fig. 2, page 92, and Plate I. Fig. 3, ^ras a fine specimen of the looser kind of adenoma. The smaller was more of an adeno-fibroma ; the fibrous tissue predominating over the glandular. This patient subsequently suckled with the breast, and was in good health five years after the operation. This patient's sister came to me in 1870 with well-marked so-called hypertrophy of her left breast. The gland was twice the size of the right. She was single, and 21 years of age. Th.% fourth case illustrates the effects of pregnancy and lactation in the growth of an adenoma. 4. Adenoma of eighteen years^ growth, loith rajnd in- crease during lactation. — Mrs. H., aged 38, a widow, the mother of one child three years old, came under my care on June 12, 1867, with a large nodular and fairly elastic tumour, the size of a cocoa- nut, in her left breast. The breast gland could be separated from the tumour without diiiSculty, and the nipple was natural. The tumour had been growing for eighteen years, slowly for fifteen, but rapidly after her last pregnancy and lactation. She would not con- sent to have it removed. The fifth case is full of interest, since it is an ex- ample of adeno-fibroma in a woman, aged 62, and was associated with a retracted nipple, a sign which is too readily accepted as an indication of carcinoma. The new growth also was said to have followed an injury. The sixth case likewise illustrates one of the same points, since the tumour was associated with a re- tracted nipple. In it, as in the former case, the growth was placed in the centre of the breast giand. 5. A deno fibroma of the breast in a ivoman, aged %2, following a blow, associated ivith retracted nipple. — Dorothy S., aged 62, came under my care on July 23, 188i, with a hard lobulated tumour occupying the Chap. X.] Benign Tumours. iii centre of tlie left breast, associated with a retracted nipple, but no axillary glandular enlargement. Tlie tumour had been growing for eight mouths, and had followed a blow received upon the part one month previously. July 30. The tumour was removed by making a free incision into its capsule, in a line radiating from the nipple. It was encapsuled and turned out with the greatest ease. A good recovery ensued. The tumour was an excellent example of adeno-fibroma. 6. Adeno-fibroma of the breast, with retracted nijyple, in the daughter of a ivoman who had carcinoma of the breast. — In 1878 I removed from the left breast of •Miss N., a healthy girl, aged 18, an adeno-fibroma of six months' growth, which was placed in the centre of the breast, and gave rise to retraction of the nipple. The case did well. I had two years previously re- moved the right breast of her mother, who was then well, for a rapidly growing carcinoma. Her mother's sister had likewise had cancer of the breast. The seventh case is quoted as a rare example of keloid attacking the scar of an old breast operation, and the still rarer absence of return after the excision of the keloid growth. 7. Adeno fibroma of breast ; excision; eight years later keloid of scar ; excision ; no return five years later. — Miss M.j aged 34, a healthy lady, consulted me on December 30, 1870, for a typical adeno-fibroma of her left breast, which had been growing for six months. It was hard, bossy, and movable. It measured four inches across. I removed the growth without in- juring the breast, and the case did well. On February 24, 1879, that is, over eight years after the operation, this patient came to me with a genuine keloid tumour in the scar of the old operation, which had been coming for seven months. Dr. Sidney Turner of Sydenham, under whose care she was, excised the 112 Diseases of the Breast. [Chap. x. keloid with a good margin of skiii, and on September 25, 1886, lie reported the lady as being well. This case is doubtless interesting, first from the fact that a keloid growth should attack the scar of an operation eight years after its performance ; and second, that on the removal of the keloid there should be no return. The eighth case is, in every way, an admirable example of adeno-fibroma of the breast. It began early in life, originated during pregnancy, grew rapidly dur- ing several puerperal periods, and shrank after lacta- tion to its former dimensions. When it was excised it weighed seven pounds, and in this operation the breast was uninjured, as it was able later on to per- form its physiological functions. The clinical history of the case extended over ten years. 8. Case of adeno-fibroma of seven pounds weight re- garded as one of hypertrophy, and removed ; the breast ivas saved, and secreted freely in later years. — Eliza K., a healthy looking married woman, aged 24, was admitted into Guy's Hospital, under the care of Dr. Ash well, on October 15, 1840, with a large tumour apparently involving the right breast. She married at the age of nineteen, in due course had a child, and nursed it with both breasts, but had to wean the infant on account of sore nipples. The right breast, as a consequence, became the seat of an abscess, which opened in many directions, and then healed. Within eight months of her first confinement she again became pregnant, and in about the twelfth week she perceived a lump the size of a hen's ^g% in the axillary border of her right breast ; it was neithei? tender nor painful, but it steadily grew, so that on the third day after a natural labour the tumour measured eighteen inches in circumference. Mrs. K. nursed only with the left breast, and the right began to decrease in size, so that in the eighth month of Chap. X.] Benign Tumours. lactation the o^rowth was not larger than an orange. At this period she became pregnant for the third time, and at the end of tlie third month, as in the second pregnancy, the tumour began again to enlarge, but more ra2)idly, though without pain ; the tumour Fig. 3. — Adeno-fibroma of Breast. thon measured twenty-three inches in circumference. At this time she came into the hands of Sir A. Coopei-, who punctured the tumour and evacuated two ounces of curded milk, the wound soon healing. She became pregnant again, was prematurely confined, and did not suckle, as the child died twenty hours after birth. The tumour, however, on this, as on the former occasions, became smaller, but not to a great extent ; it dwindled down, however, from twenty-three to fourteen inches. A fourth pregnancy then occurred, 1—25 114 Diseases of the Breast. [Chap, x when, as before, the tumour increased, and soon at- tained a measurement of twenty-nine inches, and a weight of nearly twenty pounds. At this time she came under the care of Dr. Ash well. A natural labour soon followed, and four days after parturition, X)r. Oldham, who was watching the case, reported that the circumference of the tumour had increased two inches and a half, so that it measured thirty and a half inches. Four weeks after labour the tumour had decreased five inches ; she did not suckle with the breast, although she did with the other ; on applying pressure to the breast, a little milk exuded from the nipple. The engraving above represents the appearance of the growth, which was lobulated, soft, and elastic. It measured twenty-nine inches round^ and weighed nearly twenty pounds. Dr. AshAvell regarded the disease as one of hypertrophy. In 1843 the patient passed into the hands of Mr. Stanley, who removed the tumour on July 16, 1843, leaving the normal breast, seen in the figure, on the sternal side of the tumour, unmolested. The tumour then weighed only seven pounds. * A further note of this interesting case is found in the Guy's Hospital Keports f by Mr. Birkett, who writes : " I have seen this patient several times since the operation. She has given birth to three children, and suckled them with the breast from which the tumour w:as removed. When I last saw her, which was seven years after the opera- tion, she was in good health, and quite free from any disease. I have, through the kindness of Mr. Stanley and with the assistance of the patient herself, identified the tumour in the museum of the college (Prep. 399) with the woman whose history is recorded by Dr. Ashwell, as given above. * See Prep. 399, Museum. Eoyal College of Surgeons. Drawing : Guy's Museum, 4015". Cast 27895°. t Guy's Hosp. Reports, vol. i. p. 144 ; third series ; 1855. PLATE II. Fig. 1. Fig. 2. Nipple SARCOMA OF THE BREAST. 1. Sarcoma. 2. Seotlon of harder Variety. 3. Section of softer Variety. i'5 CHAPTER XI ADENO-SARCOMATA. The sarcomata of the breast g:lancl: an eneapsulecl growth. — Sarcomatous tumours are new growths that originate in connective tissue struc- tures, and are composed of embryonic connective tissue elements. The cells are, as a rule, irregularly- arranged in an intercellular substance, through which the blood-vessels permeate. They are probably formed from the connective tissue cells, and the cells assume sometimes a spindle, sometimes a round, and but rarely a giant shape ; the name of the growth being determined by the marked predominance of any one kind of cell elements. These growths, in only exceptional instances, infil- trate a part, as do the epithelial or carcinomatous, but are more or less encapsuled, the capsule varying considerably in its density, this density being appar- ently much determined by the rapidity of the tumour s growth (Plate II. Figs. 2 and 3). The tumours, moreover, vary much in their con- siste7icy ; some are firm and approach the fibroma in feel and appearance; in such, the fibrous tis&U3 is abundant, and the cell element comparatively small (Plate II. Fig. 2). The cells, moreover, in these firm growths will probably be of the spindle shape, the cells of the connective tissue growth having developed into fibres, which form bundles, fasciculate, and con- tain within their meshes undeveloped spindle cells. These growths form the "spindle-celled" group of sarcoma, which have been described by the older writers as the " fibro-plastic," or recurrent fibroid, and so described because they are prone to recur, after it6 Diseases of the Breast. [Chap. xt. removal, in the part from whicli tliej originally grew, or in the neighbouring parts. These spindle-celled sarcomatous growths on sec- tion usually present a white, glistening, semitransr parent surface, which bulges to form a convex outline. They may be homogeneous, or to a degree lobulated, and on scraping the cut surface it will yield the oat- shaped cell, with an oval nucleus. The soft or more succulent varieties of sarcoma are probably the round-celled kind, which seem to be composed chiefly of cell elements, held together with but little fibre tissue. These are well supplied with blood, and in some cases are so vascular that they pulsate, and become, from slight injury or other cause, the seat of blood extravasation. Such tumours are of rapid growth, and present in section a white medullary or a more or less blood-stained convex surface (Plate II. Fig. 3). In a clinical sense there are, however, great difficulties in correctly diagnosing these forms of tumour. In some, again, where much blood has been ex- travasated, the cell elements are difficult to find ; indeed, the tumour seems to be but a blood clot. From such tumours of the breast I have known a quart of fluid, coflee-ground, or almost pure blood, drawn ofl'. Many round-celled sarcomata have spindle cells and fibres mixed with them. Many lie simply em- bedded in the tissues, and turn out like loose bodies ; such have a very glistening convex surface in section, and seem to a degree translucent. They are at times, though rarely, multiple. All forms of sarcomata, besides recurring locally, tend, as is well known, to disseminate themselves by the blood-vessels. At times even they may spread through the lymphatics ; thus local recurrence, vascular and lymphatic infec- tion, conspii^e to produce the most inveterate form of malignancy. Chap, xr.i A DENo- Sarcomatous Tumours. wj When any of these connective tissue tumours originate in the breast, which is composed of gland structure, in addition to connective tissue, some of the glandular elements, either tubes or their csecal terminations, are mixed up with them. Under these circumstances, the anatomical struc- ture of the growth becomes modified, and thus it is that the more expressive term " adeno-sarcoma " seems to be applicable. In some cases these glandular elements will form but a very small part of the tumour, and will be detected scattered about its tissue only after a very careful examination, whilst in other cases they will be met with in abundance, mixed up with the other elements. It is this mixture of gland structure with the sarcomatous elements that special- ises the connective tissue tumours of the breast, and more than justifies the retention of the term " adeno- sarcoma. " It is difficult, if not impossible, in the present state of our knowledge, to say in what proportions of sarcomatous tumours the round-celled, spindle- celled, or giant-celled neoplasms predominate. My own material, although extensive, is not conclusive upon the subject ; indeed, I should say, after close examination of notes of cases, that the majority of them are of the mixed form, that is, made up of round and spindle cells in ditferent proportions, the giant- celled variety being rare, and the melanotic very so. In a large proportion of cases, I should say in half, the adeno-sarcomatous tumours of the breast are associated with cysts, when they are known as cystic sarcomatous tumours. To these, special attention will be directed in chapter xvi. In the present chapter attention is alone drawn to the more solid varieties. Gross has attempted to strike an average as to the relative frequency of the different varieties of solitl sarcomata, and states that sixty-eight per cent, of one it8 Diseases of the Breast. [Chap. xi. hundred and fifty-six cases collected and seen by him, were of the spindle-celled variety, twenty-seven per cent, of the round-celled, and five per cent, of the giant-celled. By this estimate, two out of three cases are spindle-celled tumours. From a clinical point of view there is, however, no great necessity for separating the diiFerent varieties of tumours, beyond recognising the general fact that the more elementary the cell structure of which it is composed, and the greater the proportion of cell elements which build it up, the more rapid will be its growth, and the softer its structure ; the greater also will be the probability of a speedy return of the tumour after removal, and the stronger the fear that secondary growths will take place in the viscera or other parts. On the other hand, when the cells tend towards spindle shape and are not numerous, when the tumour is generally firm in consistence and slow in its growth it is less likely to return rapidly after removal, as well as to affect other parts. In short, whereas the former or softer type of tumour ap- proaches the carcinomata in its natural course, the latter or firmer type tends to follow the course of the benign or non-infective varieties of tumours. The sarcomata in the breast differ also in them- selves as much as the sarcomata of connective tissue are known to do ; and they may appear either as firm or soft succulent growths, with little or much blood in them, or almost as blood tumours. The amount of cell elements, as well as the character of the cells, will probably vary in every example. Where the cells are few and connective tissue fibres abundant, the structure of the growth will be firm ; where the reverse holds good, and the cell elements predominate, it will be soft and medullary. In the matter of vascularity, these embryonic con- nective tissue tumours vary materially ; some have a C hap. X T . J A DENO-Sa R COMA TO US TUMO URS. I 1 9 perfectly white and creamy appearance, whilst others possess a jnnkish, semitransparent surface. A few are very vascular, and show on section, scattered through their tissues, innumerable vessels ; whilst in some cases the growth seems to be so full of blood as to appeal- as a blood cyst, or tumour ; such cases as these have suggested to pathologists the probability that the embryonic connective tissue cells themselves possess the power of forming blood-vessels and blood corpuscles, as a pathological process, in the same way as they are known to do in foetal life as a physiological process in the embryonic mesoblast; the blood-form- ing function of the connective tissues of the mesoblast in embryonic life having been re-awakened, after its normal period of activity has long past, to form a sarcomatous tumour of a sanguineous type. Dr. C. C.Veighton has cleverly worked out this view. These sarcomatous neoplasms in their clinical features simulate the more benign "adeno-fibromata." Like the adeno-fibromata, they are encapsuled, but they are far more intimately connected with the breast than are those growths ; they may be said, indeed, to be more closely connected with their capsule to the breast than are the adeno-fibromata, and they can rarely be enucleated from their beds in the same way. As primary growths they never infiltrate the breast, in the characteristic way of the carcinomata. As secondary or recurrent tumours they do in excep- tional instances. They grow and separate tissues like the adeno- fibromata. They also stretch the integuments covering them in, and even cause their rupture ; and when this event has taken place, the neoplasm bursts forth in all its force, and shows itself as a soft; sprouting, fungating, and bleeding mass, which the old authors called a fungus hajmatodes. I20 Diseases of the Breast. [Chap. xr. These neoplasms grow rapidly, far more so than the adeno-fibromata or the majority of cancers ; a tumour of this kind may attain the size of a cocoanut in three or less months. At times they grow slowly at first, and then suddenly increase at a rapid rate. They also speedily undergo degenerative changes and break down, showing then in section great cavities ; at times they even slough. The outline of these tumours is as a rule more uniform than an adeno- fibroma, it is rarely so lobulated ; it usually originates as an isolated growth ; it is rarely, if ever, multiple. It is never so movable within the gland as is an adeno-fibroma, but seems part and parcel of the lobe of the gland in which it originated. It is usually as movable with the gland as an adeno-fibroma. It is rarely associated with any lymphatic glandular en- largement, although in exceptional cases it may be ; this complication is more likely to occur when the skin becomes much distended, and consequently irri- tated by the growth, than under other circumstances. In some of the worst examples of this disease the lymphatic glands are never involved. " Sarcoma," writes Gross (p. 22), " however, may ex- tend along the blood-vessels and invade the adjoining tissues without its capsule being necessarily destroyed. Hence, dining their further growth and extension, sarcoma, like carcinoma, exhibits malignant attributes, as evinced in the latter by the continuous growth of the cells into the coverings of the mammae and the subjacent structures, and by their transportation to associated lymphatic glands and the viscera, where they proliferate and supplant the natural tissues ; and in the former by the same phenomena, with the ex- ception of the conversion of the lymphatic glands into secondary growths." These sarcomatous growths likewise simulate the carcinomatous in their tendency to recur, and, what is Cliap. XL] AdENO-SaRCOMATOUS TuMOURS. 121 more, in their rapid tendency to recur. It ofton happens that a second tumour will appear before the wound of the operation for the removal of the first has closed ; so rapidly, indeed, may this apparent re- currence ensue, that the surgeon is led to think that what is regarded as a recurrence may have been but a continued growth of some part of the neoplasm that had been left behind, or some tumour which had not been discovered. In many cases he will doubtless be right in his suspicion ; but in others all evidence upon the point is deficient, and the reappearance of the growth must be regarded as a recurrent growth. These local recurrences may continue for many times. I have in one case already operated seventeen times in the course of three years, and the disease is yet quite local. {8ee case 1, chapter xx. page 335.) In some cases the disease not only returns locally, but like the carcinomata involves other organs, and particularly the viscera. Gross states "that mammary sarcoma recurs locally in 61*53 per cent, of all in- stances, and that it gives rise to secondary deposits in distant organs in 57 "14 per cent. ;" whilst "in carci- noma 88-35 per cent, of the local recurrences are met with in the first year, while only 50 per cent, of the cancers affect distant parts." It is, however, to be remembered that Gross draws his experience from selected cases, in which the proof of the sarcomatous return of the growth was determined by histological examination. These sarcomatous growths rarely attack the breasts of young women, but rather of those over 30 or 35, and they are not uncommon in women about fifty years of age. They are found also in male sub- jects ; out of 68 examples of sarcomata of the breast consecutively observed in four large London hosi)itals, according to Dr. W. Williams, two were in men. Diagnosis. — The diagnosis of an adeno-sarcoma 122 Diseases of the Breast. rchap. xi. from an adenoma or adeno-fibroma is difficult, and in many cases clinically impossible. Its true nature is to be determined better by its progress and clinical history than by its physical features. A lobulated, slow-growing, firm, fleshy, movable growth in the breast of a young woman is probably a "fibroma," and not a sarcoma ; whilst an ovoid, smooth, elastic tumour, of somewliat rapid growth, in the breast of a woman over thirty, is probably a sarcoma. The younger the patient, the more lobulated the neoplasm, and the slower its growth, the greater the probability of the tumour being a fibroma. The older the patient, the smoother the outline of the tumour, the more elastic its feel, and the more rapid its growth, the greater the probability of the neoplasm bemg a sar- coma. When the integument covering in the tumour, which was solid, is ulcerated, and the growth appears through the orifice as a sprouting, fungating mass, the disease is probably sarcomatous, although, should the disease have been cystic, this conclusion would not be so clear. As to the relative frequency of adeno- sarcomatous and adeno-fibromatous tumours, out of my last hundred cases of these collective growths but four were pronounced to be sarcomatous. "A tumour,'"' writes Gross (p. 99), "of soft, elastic, apparently fluctuating consistence, which attains the volume of an adult head in a few months, can scarcely be anything else than a small-celled sarcoma. On the whole, the diagnosis is based upon their indolent origin, lobulated outline, rapid increase, large di- mensions for the period of their existence, freedom from lymphatic involvements, and marked tendency to ulcerate; upon the not infrequent discoloration of skin, enlargement of the subcutaneous veins, and possibly, ele^-ation of teuiperature ; upon the suffermg which they awaken late in the disease, and upon their greatest frequency after the thirty-fifth year." Chap. XI. 1 Adeno-Sarcoma'IOUS Tumours. 123 Treatment. — These neoplasms cannot be taken away too early ; they should be excised as soon as they are discovered. They should not only be ex- cised, but the pai'ts around them should likewise be taken away, that is, the lobe in which the growth originated. The whole gland should only be removed when it seems to be involved in the disease ; it is better, however, to err in these cases by taking away too much than too little. Recurrent growths should likewise be dealt with in the same thorough way. These are at times multi- ])le, and when so, the operation must be extensive. I have removed recurrent growths from one patient seventeen times in three years, and at the last opera- tion, in 1887, the disease was still local. Indeed, there is good reason to believe that by removing the local affection, even after many recurrences, the disease is prevented from becoming a general one, and in- volving internal organs. In a case of small spindle- celled sarcoma. Gross succeeded, after removing fifty- two tumours by twenty-three distinct operations (the last few of which included portions of the pectoral and intercostal muscles, in a period of four years and a half) in checking the reproductions, and the patient was perfectly well nearly eleven years subsequently. Gay, Birkett, Heath, S. D. Gross and Haward have likewise reported cases, showing the advantages of repeated operations in cases of recurrent sarcoma. In many of these cases, after removal of the tumour, it is wise to leave the wound open, and let it granulate, after having well swabbed its surface with a twenty per cent, solution of chloride of zinc. I have thought that this plan of treatment destroyed siich cell elements as might have remained after the opera- tion, and in this way retarded, if not prevented, re- currence. When lymphatic glands are enlarged they should be taken away, but the prospects of anything 124 Diseases of the Breast. [Chap. xi like a cure under these circumstances are very feeble. Indeed, when the lymphatic glands are in- volved in sarcomatous growths, the prognosis is as bad as possible, and the surgeon should consider care- fully as to the expediency of advising any operation. It may safely be said that it can be in only ex- ceptional cases a justifiable measure. By way of further illustration of the subject, the following cases may be quoted : 1. Adeno-sarcoma of breast ; excision of tumour ; recurrence of growth; ahility to suckle ivifh breast between lohile ; excision vnth the breast; well two years later, five years after the appearance of growth. Elizabeth M., aged 36, was admitted into Guy's Hospital under my care on the 14th of July, 1880, and was discharged on the 16th of August, 1880. The patient is a married woman, and has eight children, seven of whom are living. She was in Lydia ward three years ago under my care, when I removed a tumour from her breast. Her father and mother are both alive ; there is no history of cancer with them ; one of the patient's brothers died of tumour of the liver. The old report of her case describes her as a healthy looking, well-nourished woman ; she entered the hospital 7th June, 1877, and then had a large tumour occupying the left breast, but extending chiefly downwards, and outward towards the left axilla. There was a scar to the outer side of the nipple, which was caused by a surgeon making an incision some weeks previous. The circumference of the left breast was 18 inches. On June 19th, 1877, patient was put under chloroform, and Mr. Bryant made a transverse incision eight inches long, reaching from the outer boundary of the tumour, inward and towards the level of the nipple, so that the growth was removed with- out extirpation of the breast. A large axillary gland Chnp. XI.] Adeno-Sarcomatous Tumours. 125 was also removed ; the great size of the arteries was very noticeable, one of these being as large as the radial. The growth weighed 21bs. 4ozs., and was com- posed of a number of cysts, some containing a milky lluid, and others more solid contents. The patient left the hospital on 18th July, with the wound almost healed, and in a fairly satisfactory condition. Since leaving the hospital, the patient has had one more child, and she has been able to use the left breast in nursing ; the child was weaned about twelve months since ; aboiit this time she first noticed a small lump just above the nipple, which has been increasing ever since. On admission there is a large lobulated tumour, divided into, two chief parts, involving the left breast. One of these parts occupies the central or upper half; the other, which is the smaller of the two, is placed on the axillary side of the gland. The tumour is above the level of the old cicatrix. It is freely movable, with a lobulated surface, elastic to the touch ; hard in some places and moderately soft in others, and it is cystic in character ; the skin over the tumour is not involved. One boss which is most prominent, and placed just above and to the inner side of the nipple, is inflamed, and painful. On July 20th, 1880, the tumour, with the breast, was removed, and a good recovery followed. The tumour was everywhere encapsuled, and was composed of many lobules, separated from one another by fibrous septa. Some of these lobules grew into the walled cysts, which contained little or no fluid, their walls being in contact. The growths in these cysts were in some cases lobulated finely on the surface, whilst in a few they resembled in colour and smoothness a mucous nasal polypus, although in con- sistence they were a little firmer. The majority of the lobules showed on section a finely lobulated 126 Diseases of the Breast. [Chap. xi. appearance, the outlines of the little lobules being crescented, some having a distinct cavity in the centre. No communication could be traced between the various cysts, nor could any be traced directly to the nipple. Some parts of the growth were firm, hard, and fibrous ; there were no blood cysts or any translucent-looking material, in the growth. In some of the nodules (felt to be elastic during life) there were many elongated slit-like spaces with smooth walls, the bounding material being acinous. In Sept., 1882, this woman was still well. 2. Spindle-celled adeno-sarcoma of breast ; tumour iveighing tivo pounds on removal; recovery ; patient well six years later. — Matilda H., aged 49, the mother of three children, the youngest being 18, came under my care on Oct. 7th, 1874, with a large tumour apparently involving the right breast. The tumour had been growing for two years, and when first discovered was about the size of a nut ; it has grown steadily, but for the last two months rapidly. It has never been the seat of much pain ; an occasional dart of pain through it is all she has felt. When seen, a smooth globular swelling occupied the position of the right breast. The skin over it was stretched, and the circulation through it was im- peded, as shown by the enlarged veins. The nipple was flattened, and the axillary lymphatic glands were natural. On October 13th the tumour and breast were excised, and a good recovery followed. The tumour was found to have been placed behind the breast, or rather in the posterior part of the breast. It was closely connected with the gland, but not infiltrating it. On section it was made up of fibro-cellular elements, containing within its meshes spindle cells. It weighed two pounds. Six years later this patient was quite well. 3. A deno-sarcoma (spindle-celled) of breast; excision ; Chnp. XI.] Adeno-Sarcomatous Tumours. 127 cure ; patient well two and a half years later. — Fanny C, a married charwoman, aged 50, the mother of five chihlren, all of whom she suckled, came under ray care Jan. 25th, 1878, with a tumour in the upper part of her right breast, which she had accidentally discovered six weeks previously. It was then the size of a pigeon's e^fg, smooth and painless. When coming under care the tumour had much increased ; it was about two and a half inches in diameter, firm and fleshy to the feci, and fixed in the axillary lobe of the right mamma. The skin over the tumour was healthy. Nipple natural, axillary glands not to be felt. An adeno-sarcomatous tumour was diagnosed, and re- moved, with the breast, on Jan. 29th, and the woman did well. The temperature never rose above 99° after the operation. Two and a half years subse- quently she was known to be well. The tumour, on examination, was found to be en- capsuled, but closely connected with the breast. It was a semitransparent, succulent, very vascular neo- plasm, and under the microscope was clearly a spindle- celled sarcoma. 4. Adeno-sarcovia of breast ; excision of the gland and tumour ; two years later the opposite hreast became involved; this was excised; and two years later still the -patient was luell. — Mary S., aged 33, a single woman of healthy aspect, came under my care in April, 1877, with a swelling in her left breast, which she had detected as a small lump eight months previously. When seen, a tumour was readily made out to exist in the upper and outer border of her left breast, which was so closely connected with the gland, that both moved together. The nipple with the skin over the tumour was natural, and the lymphatic glands were not enlarged. On May 15th an incision was made into the tumour, and as it was found to be intimately connected with the breast gland, both were 128 Diseases of the Breast. [Chap. xi. removed. The patient did well. The growth was found to he a spindle-celled, sarcoma. In August, 1879, that is, two years after the operation, the patient re-appeared with a growth in the right breast, which had been increasing for one year, and followed the same course as the one in the left. It was placed in the upper part of the gland, and seemed to be part of . it : it measured about two inches across. On August 12th the breast and growth were removed, the patient doing well. The tumour was precisely of the same character as the former one. Two years later the patient was well. 5. Round-celled adeno-sarcoina of both breasts ; removed of both ; imtient well tv)o years later. Mrs. G., aged 24, the mother of one child, consulted me in December, 1868, for a swelling the size of an egg in her right breast, which she had discovered during her only pregnancy, four months previously. She had been suckling, when I saw her, three months. The swelling was fleshy, smooth, and j)ainless, and was clearly growing fast. Weaning the child was advised. By July, 1869, the tumour had increased to nine inches by seven in diameter ; the skin over it was healthy ; nipple natural ; axillary glands uninvolved. It was then removed, with the breast, by the late Mr. Ashforth of Rutland, and sent to me for examination. It was a soft, succulent, pinkish, homogeneous growth which, on section, exuded a glutinous fluid. It was made up of round cells_, and some adenoid tissues. The patient did well. Four months later a like growth appeared on the left, or opposite breast, with some enlargement of the axillary glands of the same side. These I removed, with the breast at once. One year later I saw this lady with an excellent cicatrix, and after the lapse of another year she was reported as well. Chap. XI.] Adeno-Sarcomatous Tumours. 129 6. Large cystic sarcortia of the left breast ; am-puta- tlon ; recurrence ; exhaustion ; result, death. — Emma S., aged 52, a cook, was admitted into No. 3, Lydia ward, under the care of Mr. Bryant, on December 4th, 1883, and discharged on the 15th February, 1884; she was re-admitted on the 2nd April, 1884 and died on the 6th May, 1884. The patient is a single woman ; her father and mother died of old age ; she has one brother and five sisters, all healthy. Fifteen years ago patient had small- pox, but since has been quite healthy until ten months ago, when she had bronchitis. About this time she noticed a small hard lump, the size of a kernel, in her left breast, just above the nipple ; the growth slowly in- creased ; it was not painful ; seven months later it had attained about the size of a fist; no aggravation of symp- toms took place during the periods of menstruation. On admission, the patient is a fat, healthy looking woman ; there is a large-sized tumour occupying the position of the left breast which measures 30 inches round its base, 16| inches across the nij^ple from above downwards, and 17|^ inches from right to left in the same direction (Plate II. Fig. 1). From the measurements it will be noticed that the growth has doubled in size in the last two months. The sur- face generally of the tumour was congested, with enlarged and engorged subcutaneous veins over the upper two-thirds of its surface ; the skin was tense and shiny, and over several areas the tumour was more prominent and the skin blue, with a mass of dense network of enlarged veins ; there were two large bosses above the nipple, which were raised, measuring 3 inches by 3. Areola and nipple were somewhat stretched out ; there was no evidence of fluctuation ; the surface above the nipple was tender and painful to the touch, and gave evidence of indistinct fluctua- tion in several spots; there was no involvement of J— 25 130 Diseases of the Breast. [Chap. xi. the axillary glands ; the patient complains of a darting pain at times through the tumour ; the temperature, just after her admission, was 99°. On Dec. 7th Mr. Bryant removed the tumour with the breast, and the case ultimately did well; the patient leaving the hospital convalescent. The patient was re-admitted on April 2nd, 1886. History of the secondary growth. — The patient noticed round and over the old wound, before it had entirely healed, some return of the growth ; on re- admission the swelling had extended all over the left breast, and at an elevated spot, near the axilla, it had broken down. The discharge from the growth was very small at first, but it has since gradually increased, and pain has accompanied it more or less all the while. She has some nerve pain down the arm to the elbow. Condition on re-admission. — The patient looks very healthy, but this has been her general appear- ance all along. The seat of the former tumour is involved with new growth, but there is no lymphatic glandular enlargement. The tumour extends exter- nally to the anterior fold of the axilla ; internally as far as the middle of the sternum ; above as high as the upper margin of the first intercostal space ; and below it runs downwards to the eighth rib. It pre- sents two sloughing surfaces, one about two inches square, over the sternum, at the upper and inner angle ; the growth being composed of four nodules which have united and formed one mass, the surface of which is sloughing. About two inches external to this is another single nodule, which has a sloughing surface ; the edges of the two are clean cut and well defined, and over the whole circumference there are various nodules, which are soft and rather painful. The skin appears brawny and of a red colour. The whole mass moves Chap. XL] Melanotic Sarcoma. 131 freely over tlie ribs and deep parts. The patient's powers steadily failed under the exhausting effects of the discharge from the broken-down growth ; and she died on May 6th. No secondary growths were found. Melanotic sa.i'coina of the mammary gland is a very rare affection, and as a primary disease I believe it to be unknown. In the two following cases it was of a secondary character. 7. Melanotic sarcoma of the breast, skin, and axillary glands, folloioing the removal of a groioth originating in a mole. — Lydia M., aged 3G, a married woman, the mother of one child, nine years old, came under my care in December, 1857, with her right breast covered and filled with " lumps " the size of nuts ; the skin tumours were evidently of a melanotic nature, and extended to the integument covering the sternum and abdomen, some few being in the back. The axillary glands were much enlarged. On going into the history, this woman had had a black tumour the size of a walnut removed ten months previously from her left fore-arm, which had originated in a mole, and had been growing one year. The cicatrix of the operation wound was sound. 8. Melanotic sarcoma of breast folloioing the excision of a melanotic tumour originating in a mole over the sternum. — On October 18, 1867, I was consulted by a Mrs. M., a married childless woman, aged 55, from whose sternum a tumour had been removed four months previously, which had been growing four months in a black mole. It was removed by Dr. Richards of Redruth, when about the size of a duck's Q^g, and was supposed to have been a cancer. When I saw the patient there was clearly a melanotic growth in one breast, and many disseminated tubercles of melanotic sarcoma scattered over the sternum, breasts, abdomen, and enlarged lymphatic axillary glands, for which no operation was justifiable. 132 Diseases of the Breast. [Chap.xii. In chapter xx., wliicL. deals with associated growths of different kinds, two cases, 8 and 9, will be found in which carcinoma of the breast and melanotic sarcoma were found in the same patient. CHAPTER XIT. carcinoma of the breast (an epithelial infiltrating growth). Carcinoma always originates in epithelial tissues, and is composed of epithelial elements. These elements invariably infiltrate the tissue in which they are placed, and spread from their primary seat to neighbouring structures by a progressive in- filtration, so that as the disease advances, skin and fat, muscles, bone, nerves, and vessels eventually be- come involved, although the structures named vary in their powers of resisting the infiltrating tendency. In carcinoma of the breast, the gland structure is the one primarily involved ; and the epithelial elements of which it is composed partake of the anatomical characters of the normal epithelial lining of the ducts, or acini. The cells in the early stages of disease where they are in contact with the basement mem- brane of the gland are arranged with a certain kind of regularity; but at a later period they are most irregular, in the lumen of the duct, in the centre of the acinus, and in the connective tissue of the parts outside the basement membrane ; the vessels of the growth are distributed to the fibrous stroma of the tissue infiltrated, and not, as in connective tissue or sarcomatous tumours, between the cells. The epithelial cell elements in their infiltrating Chap. X 11.] Carcinoma. 133 progress affect the invaded tissues in a particular way, and the cells in an early, if not in the earliest period of disease are found to be placed between the normal fibres, ducts, or gland elements of the invaded struc- ture in what are called alveolar spaces. These spaces vary in shape, size, and in the arrange- ments of their epithelial contents, and each alveolar arrangement apparently de))ends, in the early period of disease, upon the anatomy of the tissue primarily infiltrated. The alveolar spaces, whether large or small, freely communicate with one another in different places, and when a section of a tumour is made, and its surface scraped, the contents of the spaces readily escape as "milky" or " cream like " cancer juice; this juice being composed of the epithelial cells, massed together, or floating in an albuminous fluid ; the cells composing the juice being large or small, with one, two, or more round or oval nuclei. This alveolar arrangement does not, however, hold good for ever; it does so only so long as any normal tissue remains uninvaded or unchanged. For it is to be recognised that in all cases of carcinoma, as the infiltration of the epithelial elements progresses, so the disa])pearance of the tissue infiltrated is to be traced, until at last the natural structure of the invaded parts, even of bone, becomes entirely replaced by the car- cinomatous elements. Over and above this, there is more or less in all infiltrating tumours a proportion of granulation or indifferent cells, from which of them- selves the nature of the tumour could by no means be distinguished. Neoplasms, like normal tissues, are liable also to certain pathological processes, and tumours of the breast are obedient to this law ; thus they may inflame and suppurate, or ulcerate, and they may likewise undergo chronic degenerative changes. The life history of 134 Diseases of the Breast. [Chap. xii these epithelial or carcinomatous infiltrating tumours is not usu illy a long one, and every such tumour having arrived at maturity, begins to degenerate and to die, the process of death being in some cases slow, in others rapid. When slow, the process is by what is known as caseation ; when rapid, by sloughing ; this latter process, ia some cases, being apparently helped by what much simulates an inflammation. At times a tumour may caseate in its centre and break down, so as to form a cavity containing a bloody or serous fluid simulating a cyst. In rarer cases the growth will undergo what is called the " colloid transforma- tion," a form of degeneration peculiar to carcinoma, and not known to occur to the sarcomatous group. Of external tumours, those of the breast are mostly liable to this form of degeneration, whilst the more common examples of colloid transformation have been usually met with in the abdomen. In this change the growth becomes a gelatinous mass of a yellow or pinkish-red colour, and on section this material flows like trans- parent honey or mucus ; it differs, however, from mucus in not being rendered opaque by acetic acid, and in containing sulphur ; the alveoli of the changed growth enormously increase in size, and the epithelial cells of which it was composed swell into glistening globes, unaltered epithelial cells being often found in the centre of the mass. In what way the epithelial cells of carcinoma that infiltrate the invaded tissue are formed and propa- gated may be open to dispute. In some cases it would appear that from either a known or unknown source of irritation, the natural elements of the epithelial tissue increase and multiply, and following the line of least resistance, dip iuto the tissues upon which they are placed, and so infiltrate them. In others, where glandular structures are in- volved, as in the breast, the epithelial elements may Chap. XII.] Carcinoma, 135 first collect within the acinus, or tubule of the gland, and then make their way into the tissues outside, from rupture of the basement membrane of the acinus wall. In a third class of cases, or perhaps in all to a degree, the disease spreads by what is called ^'- in- fection" that is, the acquired power possessed by the developed morbid epithelial cells, when coming into contact with embryo undeveloped cells, of influencing their development, and causing them to take on the epithelial form. In the same way as in the cicatrisa- tion of a granulating wound, the epithelial cells of the true skin at the margins of the sore influence the embryonic granulation tissue elements in contact with them to form new skin. How far this " infecting " power influences the young connective tissue cells to assume the epithelial form in the growth of tumours, which originate in a glandular organ, and secondarily invade connective tissue structures, it is not possible to say ; although it is probable that such an influence is an important one, since it is certain that epithelial growths increase rapidly as soon as their epithelial elements have escaped from the acini of the gland, in which they originally increased and multiplied, by what is known as ordinary generation, and become dissemi- nated into the fibrous or connective tissue structure around the gland. So long as a new formation in a glandular organ is confined within the limits of the organ; so long as it retains both in structure and func- tion the type of the normal tissue, it constitutes an adenoma. But when the new growth " becomes destructive towards the surrounding tissues," when it proceeds to infect the neighbourhood, it becomes cancerous. The additional element in the case of cancer is clearly secondary to, and not co-ordinate with, the initial disturbance. Epithelial cells, and in 136 JD IS EASES OF THE B RE AST. [Chap. XII. fact the same kind of epithelial cells, are produced in two ways, but the two modes of formation do not belong to the same category ; the one is a modification of liealthy action, and the other is simply a mimicry of the original departure from the normal. Carcinomatous tumours, moreover, at some time of their history cease to be local diseases; and it seems probable that this great change in the clinical character of the disease is marked by the patho- logical change, to which attention has just been drawn, namely, the escape of the epithelial elements through the basement membrane of the tube or acinus in which they primarily grew, and the secon- dary infection of the surrounding connective tissue by the epithelial elements. " The cancerous element in the disorder," writes Creighton, "first shows itself when the infiltrated epithelium produces what we agi-ee to call infection of the connective tissue cells with which they are in contact." How cancer spreads.— When a cancer or carcinomatous growth ceases to be a local disease, it spreads in three marked ways : by " continuous or local infection," by "lymphatic infection," or by "secon- dary vascular infection " ; and whilst in any given case one form of infection may be more marked than another, in others all forms may exist to- gether. In the breast any one or all may co-exist. By ''continuous local infection'' is meant the gi-adual involvement of surrounding structures, in the order of their arrangement, around the primary seat of the disease, by progressive infiltration, as well as by extension along the perivascular sheaths of the blood- vessels of the diseased part; this being a common feature of scirrhus. By " lymphatic infection'' is meant the infiltration of the lymphatic glands associated with the primary Chap, xii.i Carcinoma. 137 diseased centre, or its coverings, by the lymphatic ducts, the elements of the disease being carried eitlier by the lymph to the glands, or the lymphatic ducts themselves becoming directly infiltrated. By '■^secondary or vascular infection'^ is meant the propagation of the disease by other than the two methods already described, and probably by the blood currents ; the evidence of this infection being afforded by tlie existence of one or more secondary growths, similar to the primary gTO%vth, in the viscera or other parts of the body, as, for example, in the pleura or liver in cases of scirrhus. Local recurrence after removal of the primary growth in apparently the most complete manner is another sign of malignancy which is common to the carcinomata, as well as to some forms of sarcomata. It is a common feature of breast cancer. With these general remarks on carcinoma, I will pass on to consider the disease as it affects the breast, and is seen at the bedside. Sig:n$ and symptoms of carcinomia. — When a surgeon finds in the functionally inactive breast of a woman over forty years of age, or in one even ten years younger, a thickening or induration and apparent infiltration of one of its lobes, and with this local infiltration he fails to discover any other symptom or sign of a local inflammation, he is at once led to suspect the existence of a carcinoma ; and when in the course of a few wrecks or months the infiltrated lobe has increased in size, or the infiltration has spread from the lobe of the gland in which it originated, either to other lobes, or to some of the tissues that cover or lie beneath the breast, the diagnosis of a scirrhous carcinoma, or a cancerous tumour of the breast is plainly confirmed ; the spreading of the local affection being indicated by either a "dimpling," or "puckering" (Plate III.), or T38 Diseases of the Breast. [Chap. xii. infiltration of the skin covering in the lobe, or by diminished freedom of movement of the breast over the pectoral muscle. AYhen, again, a pathologist makes a section of a tumour involving the breast, and the section cuts crisply and becomes concave, shows a glistening sur- face of a greyish- white colour, and dotted over with yellow spots and streaks ; when he finds the disease to have originated in the gland structure, and to have infiltrated its tissues as well as to be deficient in everything like a capsule ; when he scrapes the cut surface, and the scraping yields a milky juice (cancer juice), which under the microscope presents epithelial cell elements, with large round or oval nuclei of great variety ; and when, on a closer histological examination, sections of the growth are made, and the pathologist discovers that these epithelial elements have been scraped from larger or smaller slit-like oval or rounded alveolar spaces lying between the tissues of the affected lobe or gland, and that these epithelial elements otherwise possess no definite order of arrangement, he at once pronounces the disease he is examining to be carcinomatous or cancerous. It must be understood, however, that there are no such special cells as "cancer cells." Those found in cancer are truly epithelial, but they are enlarged and defonned, many of which possess multiple nuclei, and are very prone to undergo fatty degeneration. Their arrangement also differs widely from the normal : they have no such regularity in their arrangement upon their basement membrane as seen in the adenomata, but their membrana propria is destroyed, and the lymph spaces of the connective tissue are infiltrated by the solid cell cylinders. Should the j)athologist, on further dissection, dis- cover that the tissues outside the area of the gland are involved in the disease; that no boundary line PLATE III. Fig. 1. Fig. 2. ^^4 ^ X^^ ''•w?^ Fig. .S. Fig. / \ <^ carcino:ma op the breast. 1. Dimpling of Skin. 2. Puckering of Skin. 3. Ati'opliic Cai'cinoma. 4. Tuberous Carcinoma. ciiap. XII.] Carcinoma. 139 of any kind can be made out to exist between the liealtliy and diseased parts; that the capsule of the gland where it originally encased the healthy lobe has disappeared, and been replaced by a new cell growth ; and that this same form of neoplasm which originated in the centre of the diseased gland has I'adiated outwardly through the capsule of the gland into the fatty structure that surrounded it, and pro- bably through this fatty structure either to the skin or the muscles beneath, so as in the former case to bring about, first, a drawing downwards of this structure (dimpling, Plate III. Fig. 1), secondly, early infiltra- tion (puckering, Plate III. Fig. 2), and thirdly, marked infiltration (indurati-on), or in the latter case fixedness of the growtli and its immobility from the ])ectoral muscle : when these facts are discovered the diagnosis of cancer is absolute. Indeed, both the clinical as well as pathological facts demonstrate that the disease, which began by infiltrating a lobe of the gland, has spread rapidly by the same infiltrating process ; that it has passed from the lobe primarily involved through its capsule, and from this through adipose and connective tissue, either to the skin itself or pectoral muscle beneath, so that at last the skin had become infiltrated, and so changed. For carci- nomatous infiltration of any tissue means eventually epithelial substitution ; and tissues that are at first in- vaded or infiltrated, in the course of time entirely disappear, their elementary tissues steadily giving way under the infective influence of epithelial infil- tration ; so that at length the natural structure of the mammary gland becomes superseded by the epi- thelial elements. From these considerations it may be asserted that four main pathological points so far stand prominently forward in carcinoma of the breast. The first being that the disease is an infiltrating one ; the second, I40 Diseases of the Breast. [Chap. xii. that the infiltrating elements are epithelial, and nothing else ; the third, that whilst the disease may- have originated in one structure, say one lobe of the breast, it will eventually locally infect neighbouring structures by a progressive infiltration (extension by local infection) ; and fourthly, that the normal structures invaded or infiltrated will eventually be destroyed and superseded by the epithelial infiltrating material. Cancerous tumours, however, whilst they locally spread by local infection, do so iji other ways, and of these, the method by lymjphatic infection is the most frequent, the epithelial elements being either carried directly by the lymph stream from the lymphatic s[)aces of the infiltrated tissue, through the lymphatic ducts, to the neighbouring axillary, clavicular, or substernal glands, or the walls of the lymphatic ducts themselv^es become absolutely infiltrated with the cancerous elements, and thus the local disease is conveyed by direct extension to the lympliatic glands themselves. It is probable that both these two methods have their influence, and that the first is the more common. Again, carcinomatous disease spreads by '■ vascu- lar infection," that is, by the blood-vessels, and so becomes disseminated broadly into the viscera and other distant parts of the body ; local infection, lymphatic infection, and vascular infection being the chief methods by which cancerous disease spreads. The varieties aaid maeroscopical features of car einoHiat oils grow^tlis. — There are clini- cally six classes of cases of carcinoma of the breast, although " the varieties of carcinoma are determined by the relative proportion of the stroma and cells, by certain degenerations and transformations, and by the accidental formation of cysts " (Gross). 1. The very slowly growing, and subsequently Chap. XII.] Atrophic Carcinoma. 141 atrophying, scirrhous carcinoma (Plate III. Fig. 3 ; Plate V. Fig. 3 ; Plate VI. Fig. 1). 2. The more common variety, or hard, fibrous, infiltrating form of carcinoma (Plate V. Fig. 2). 3. The soft, more cellular, and encephaloid variety (Plate V. Fig. 4). 4. The acute brawny cancer (Plate lY. Fig. 3). 5. The colloid cancer (Plate YI. Figs. 3 and 4). 6. The cystic carcinoma (Plate YII. Fig. 4). The first variety (Plate III. Fig. 3), or the very slowly growing, and subsequently atrophying, form of scirrhus, is the hardest kind met with, and is often described as stone cancer ; it rarely attains any large dimensions, and is characterised by its peculiar power of contracting all the tissues involved in its infiltrating influence into little more than a puckered scar, with a central hard stony nucleus. When the centre of the breast is its starting point, the breast gland, with its nipple and skin covering, may all be drawn together into a cicatrix-like fissure. And when the primary growth occupies the periphery of the breast gland, the same contractive powers will be visible, although without any retraction of the nipple. In Plate YI. Figs. 1 and 2 this condition is well illus- trated. The disease may progress so slowly as to last twelve, or even twenty years, and at the end appear only as a local disease ; whilst in other cases a tumour, that for years had grown but slowly, may suddenly take on active growth, and develop into an acute or subacute form of cancer. During the progress of this withering scirrhus, tubercles may appear in the skin of the primary growth and in its neighbourhood, which may appear and even disappear, the disease progressing and receding at the same time. Should the growth be irritated or interfered with, it may become active, and what has 142 Diseases of the Breast [Chap. xii. been a local disease will become a general one by- lymphatic and vascular infection. Patients the sub- ject of this form of cancer, as a rule, die from visceral metastatic growths rather than from the local disease. A section of a tumour, such as the slowest growing of this series, will cut crisply, present a concave sur- face of grey appearance with the remains of old gland ducts. There will exude from its surface but little juice, and this juice will contain but few epithelial cells ; and what are seen will probably be undergoing fatty or granular degenerative changes. The fibrous stroma will be abundant, and the alveoli which con- tain the epithelial elements will probably only show as slits or fusiform clefts. This form of carcinoma may clinically for a long period be regarded as a local disease, although at a later period it spreads by lymphatic iniection. In the following brief notes of cases, many of these points will be well illustrated. 1. Carcinoma fihrosum of right breast ; disajypear- ance of local disease by natural 2)'^ocesses ; death of patient of chest disease seventeen years after first appear- ance of disease. — H. B., a healthy looking, childless, married woman, aged 53, came under my care in January, 1857, with an ulcerating carcinomatous tumour of her right breast. The disease had existed for six years, and ulceration had been present for four. The cancerous surface was about the size of the palm of the hand. It was of stony hardness and firmly fixed to the muscles. Its edges were nodular and crumbly ; the axillary glands were also enlarged. Her general health was good, and as the tumour caused little pain, operative interference was rejected. In March, 1858, fifteen months later, the tumour had become much smaller, and several pieces the size of nuts had fallen ofi", having appa- rently been destroyed by the contraction of the fibrous Ciiap. XII.] Atrophic Carcinoma. < 143 elements of tlie neoplasm. The growth as a whole was much harder. General health still good. October 20, 1858, six months later, much of the original tumour had crumbled away, and the tumour was much smaller. Some tubercles had, however, ap- peared in- the skin over the sternum. April 21, 1859. Tumour continues to contract, and to throw off pieces. The tubercles in the skin are likewise contracting and becoming paler. November, 1859. Axillary glands becoming smaller and more indurated. July 23, 1861. The breast has nearly cicatrised, a mere linear puckered scar remaining, in which are one or two small hard white tubercles. All the secondary tubercles of the integument have disap- peared. January 3, 1862. Nearly cured. June 1, 1862. Only one small tubercle the size of half a nut remains in the cicatrix. ISTo fresh tuber- cles have appeared. The glands in the axilla can hardly be felt. March 31, 1863. Breast shows merely a cicatrix, in which there is only one small nodule the size of a pea. The woman in all other respects is well. May 30, 1864. The breast is still in the same condition ; one or two tubercles have appeared in the integument near the cicatrix, and have again dis- apjDeared. Two tubercles are, however, still present, June 30, 1864. The jDatient considers herself to be well. Her skin tubercles cause no pain or incon- venience. This is the last note of her case I have, but I learnt later that this patient died in 1870 of some chest trouble. The local disease had not increased. 2. Atrophic cancer, twelve years^ growth ; patient survived fifteen years. — Miss B., aged 50, who had had atrophic cancer of her left breast for twelve years, 144 Diseases of the Breast, [chap. xii. with enlarged axillary glands, came under my care on September 13, 1868, when the nipple and skin around, and breast gland were all involved in a hard, puckered, cancerous tumour. This patient lived for three years, and died from some acute chest trouble. 3. AtroijMc cancer oftiventy years^ standing. — Jane H., aged 72, the mother of two children, and a widow of fifteen years, came under my care in 1869 with a puckered carcinomatous infiltration of her left breast of twenty years' existence. The whole gland, and the skin over it, and the axillary glands were involved, although the nipple was natural. Secondary tubercles were very general in the skin. This patient died one year later of asthenia. 4. Atrophic cancer of breast, nine years. — Bridget M., aged 56, the mother of three children, came to me on August 18, 1868, with an atrophic cancer of her left breast, which had existed for nine years, with skin tubercles for the last two years over the breast and sur- rounding skin. She was steadily losing strength, and died within a year. 5. Atroiohic cancer of breast, eight years. — Ann H., avn table wlio were or liad been married, 360 were prolific, or 74 per cent., and 125 sterile, or 26 per cent. A large proportion of the j)rolilic women were so to an extreme degree, ten and more children to one mother being a common note to find recorded. Winiwarter has noticed this same point, six children in his cases being frequently recorded to one mother. The breasts of married women and of those in whom the gland has been the most active are apparently more liable to cancer when the period of gland activity has passed than are the breasts of sino-le women. A gland that has been functionally active being more prone in its period of obsolescence to become the seat of carci- noma than another which has never been called into activity. The above facts show how erroneous is the common assertion that the unmarried women are more liable to carcinoma of the breast than the married. Breast involved. — In 300, or half of the 600 cases, the right gland was the seat of disease ; in 272 the left ; and in 28 both glands were involved ; double cancer being apparently present in 5 per cent, of all cases, or in 1 in every 20. InflMence of menstrnatioH.— My own facts are not clear enough upon this point, but Birkett, who is known to be a very careful observer, states, " that in a large majority of the women who have cancer of the breast the function was persistent at the moment of the development of the disease." That is, in 70 per cent, of his cases the catamenia were persistent, and in 30 per cent, it had ceased. Gross states that in his cases 61 per cent, of the women were menstruating, and in only 6-4 per cent, of them was there irregularity in the performance of that function. In 39 per cent, the catamenia had ceased. Winiwarter does not believe that menstruation has Chap. XII.] Carcinoma. 151 any ?etiological connection with carcinoma, and in tliis I quite agree. Diirntioii of disease wlien first seen.— This point was noted in 504 of the 600 cases. In 221 the disease had existed under a year. ,, 165 it had been discovered between 1 and 2 years. „ 39 it had existed between 2 and 3 years. „ 25 „ ,, „ 3 „ 4 „ ^ ,, 22 „ ,, „ 4 „ 5 ,, 1 15 per cent, over ., 15 ,, ,, „ 6 ,, 7 ,, J 3 years. „ 10 » „ „ 8 „ 9 „ J ,, 7 it had existed from 10 to 20 years. From tliese facts it is clear that in three out of four cases of carcinoma of the breast the disease when first seen by the surgeon has usually existed for less than two years. In the fourth case it has existed from two up to twenty years. In the majority of these latter cases, and in all those that had given a history of more than four years' duration, the disease was pro- bably of the atrophic kind. I should not, however, have believed, if I had not made the above analysis, that so large a proportion of the cases of carcinoma of the breast of which I had taken notes had been of so chronic a nature as these facts indicate, for it is to be remembered that these figures give the duration of the disease before treatment, and if the benefit of treat- ment is added, a considerable extension of time would probably have to be given. If we accept Paget's conclusion, that the average duration of life in carcinoma of the breast is about four years, and my own cases confirm this view when thus divided, we must accept as e(i[ually true a more important and hopeful conclusion, that a large number of patients, approaching a third of the whole number, survive this period for montlis or years. This conclu- sion will be very palpable on looking at the following 152 Diseases of the Breast. [Chap. xii. table, composed of an analysis of 72 operation cases, the results of which I have been able to trace. Table showing the duration of life of 72 cases after the carcinomatous tumour had been discovered, all of which had been operated upon with success. g 22 ^0 U 2 2-7 8 11 2 2-7 In 8 or 11 p. c. the disease ran its course within 12 montlis. 16 22 p.c. patient died between 12 and 24 months ,, .., „ 24 „ 36 „ 3 „ 4 years. ,, 5, i^ ^^^ Mt\ year. ,, "between b\ and 6 years. ., lived eight years. 2 lived nine and 6 ten years, or 14 per cent, over six years. 55 per cent, of the whole number sank within three years, and 44 per cent, over three years ; these pro- portions being precisely those brought out by Sir J. Paget in his analysis of cases which had not been interfered with. But my table tells us likewise that 18 out of the 72 cases, or at least one-fourth of all cases operated upon, lived from 5 to 10 years. It is well, therefore, to have this fact always before us, and that whilst we assert in all truth that one half of our patients will die within the three years, we can with equal justice lead any individual patient to hope that her chances are equally good to live from 5 to 10 years. Indeed, we may with a clear conscience admit, that whilst one-third of all cases die within two years, two-thirds wiU live from 3 to 10 years; half of these surviving from 5 to 10 years. The surgeon, with these facts before him, is there- fore justitied in placing before any individual patient the same hopeful aspect of her case, and thus giving encouragement where so much is needed. I quote Paget's table of 61 cases, the records of which were complete, since it deals with cases which Chap. XI T. Carcinoma, 153 liave not been interfered with, whereas my tahle in- cludes only cases after operation. 34 cases under 3 years, 7 died between 6 and 12 months. 7 „ „ 12 „ 18 „ ,^ " " ^\ " ^01 " r or 55 per cent. 10 „ ,, 2 „ 2| years. I ^ 2 „ „ 2^,, 3 „ 12 „ „ 3 ., 4 „ j o " " fi " 8 " V ^"^ f^^^^^ over 3 years, J " " g " jQ " ( or 46-2 per cent. !! !' 10 ',', 20 '', ) Baker gives the average duration of life 43 months ; Sibley makes it 32 months ; Gross only 27 months withoiit operation, and 39 months with. Carcinoma of the breast comijlicated with iireg- nancy. — Should the breast of a pregnant woman be the seat of cancer, the disease as a rule will progress rapidly, and should the stage of suckling be reached, its increase will be still more rapid. These cases are happily rare. I record a few examples. Mr. Annandale rejDorts that he once operated upon a mother and daughter for scirrhus of the breast, both within two weeks ; the daughter was nursing when the disease first showed itself, and in her case its pro- gress was much more rapid than in the case of her mother ; and further, the disease returned in the daughter's breast much earlier than in the mother's. 1. Extensive cancer of breasts and integument of the chest and abdomen, associated ivith pregnancy folloiving swpiniration of breast; death in eighth month of pregnancy. — Mrs. M., aged 35, the mother of nine children, and the first eight of which she suckled, came to me in 1868, when she was four months pregnant, with the right breast and skin over it, as well as the integument of the chest, side, and abdomen, generally infiltrated with carcinoma. In 154 Diseases of the Breast. [Chap. xii. fact, she was skin-bound. The breast with the skin in several parts was ulcerated. The right axillary glands were enlarged, and the right arm cedematous from venous obstruction. The disease in the right breast had appeared as a lump in the gland, which was left after an abscess that formed when suckling her eighth child two years previously. The left breast was likewise infiltrated with carcinoma, and this had followed an abscess after the ninth child, ten months previously. This patient died from asthenia about the eighth month of her pregnancy. 2. Cancer of breast, followed by pregnancy, and mis- carriage ; after which rapid groioth of disease ; death. — Mary L., aged 44, the mother of four children, all of whom she suckled, came under my care on January 19th, 186-5, with carcinoma of her left breast. The disease had been coming for two years, and had in- creased slowly ; seven months ago she became preg- nant, since then the disease has progressed more rapidly ; she miscarried at the fifth month, that is, seven weeks ago. At present the mammary gland as a whole is infiltrated, and fixed to the pectoral muscle ; the skin over the glaud is fixed, puckered, infiltrated, and ulcerated around the gland ; in the skin are many small tubercles of cancer; the axillary glands are slightly enlarged. Later on the ulceration spread fast, and the tubercles multiplied over the skin and on the right breast. In September the patient died with chest complication. Her paternal grandmother had died, aged 87, with chronic cancer of the breast; \i^y paternal aunt also, with the same disease, aged 65. 3. Cancer of breast coming on during i^regnancy ; acute progress involving both glands ; early death. — • Eliza S., aged 49, the mother of three children, whom she did not suckle, the youngest being four months Chap. XII. 1 Carcinoma. 155 old^ came to me on March 18th, 18G9, with a lump in her right breast, which she had discovered three moiitlis before her last confinement, and which had rapidly- increased. When seen seven months after its appear- ance, the whole gland was infiltrated with disease and the skin over it was brawny. The tumour was fixed to the chest ; the axillary glands enlarged. There was pain down the arm, which was oedematous. Four months later the disease had affected the opposite breast, and the woman soon sank. The patient's mother had died from tumour, and her sister from cancer of the breast. 4. Cancer of breast with retracted nip2:>le, which pre- vented suckling, following labour. — Mary B., aged 38, the mother of five children, the youngest being five months. She had suckled all with her right breast, but not with the left, as the nipple was retracted. JSTovember 4th, 1869. The left breast was infil- trated with cancer, associated with enlarged axillary glands. It had commenced after her last confinement, five months previously. Six months later this woman died. 5. Acute brawny cancer of breast, appearing during lactation. — Eliza W., aged 35, the mother of four children, the youngest being fifteen months, all of whom she had suckled, came under my care on January, 1871, with infiltration of the left breast and a brawny condition of skin over it. The disease began three months before, during suckling, as a lump which rapidly grew. The skin over the right breast was mottled and was already becoming infiltrated in lines, probably lym))hatic. On March 2nd the woman was sinking. Her mother's cousin had cancer, and two cousins, one paternal, and one maternal, had tumours. Oeiieral condition of patient the subject of carcinoiBia. — An old prejudice still exists in 156 Diseases of the Breast. [Chap. xii. favour of the presence of a cachexia in cases of cancer ; although a very little clinical experience is wanted to learn that this 2:)rejudice is wrong, and that there are few patients admitted into metropolitan hospitals with a more general healthy aspect than those who have cancer of the breast. At least half the cases who have this disease present the appear- ance of perfect health. Two-thirds of the remainder look as healthy as the bulk of those who are doing the work of life well. Whilst in the sixth, not in- cluded in either of these classes, some general evidence of illness may be made out ; the general evidence de- pending more upon mental anxiety and apprehension than any real influence of the disease upon the func- tions of the bod}^ To see what is known as cachexia, the surgeon must go into the cancer wards of a hos- pital, in which the sutFerers from cancer are retained until the end, that is, until life is slowly sapped by haemorrhage, discharges, pain, and the interference with some one or more of the important functions of the viscera fi'om metastatic or secondary growths. These patients look ill and cachectic, it is true, but probably not more so than others who are suffering in an allied way, though not from cancerous afi'ections. The cachexia of cancer, in fact, differs in no way from that of any other exhausting disease. When it exists it indicates the presence of some affection which is undermining the patient's strength, which may be cancer, but it may be any other form of disease. The observations of other writers support these conclusions, for Gross states that fifty -one per cent, of his cases were in good health, nineteen per cent, were pale and thin, and twelve per cent, were decidedly broken down from the effects of the disease. He adds also that the nutrition of scarcely one in twenty suffers previous to sixteen months after the detection of the growth. Paget found that sixty-six out of Chap. XII.] Carcinoma. 157 nine by -one cases presented the characters of good health ; nine were in but moderate health, and only sixteen were sickly. Hei'ele ; ca7icer of breast. — Eliza S., aged 62, who had been married 35 years, and had 6 children, came to me on February 19th, 1865, with an infiltration of the upper lobe of her right breast, which had existed for one year. For two years previously she had had eczema of her nipple, and during this time the nipple projected ; for three years before the eczema appeared it had been retracted. In June, 1865, the skin over the breast was infiltrated with cancerous tubercles. I then lost sight of the patient. This patient's mother died from cancer of the breast, and two of her brothers of internal cancer. 4. Paget' s disease of nipjjle, folloiced hy carcinoma Chap. XII.] Carcinoma. 169 destroijed loith cautery. — Mrs. B., aged 60, a married, childless woman, came to me March 26, 1877, with eczematous ulceration of the right nipjile and areola, of four years' standing. The nipple had gone, and much of the areola. The sui-face was ulcerated, but not thickened. Total destruction of the whole surface witli a cautery was carried out, and the parts healed. Some months later the hardness reappeared, and ulcerated, and in 1879 the right breast was excised, and convalescence followed ; but the disease soon re- turned, and invaded the opposite breast. The patient died in 1882. 5. Carcinoma of breast folloioing eczema of nipple. — Miss S., aged 57, consulted me in May, 1875, for an eczema of her nipple which had existed for many months. When seen by me, there was marked in- filtrating carcinoma of the breast ; retracted nipple, and a red, raw surface in the position of the nipple and its areola. Operation advised, but refused. 6. Carcinoma of breast following eczema of nipple. — Mrs. S., aged 45, the mother of 5 children, came to me in October, 1877, with an eczema or rawness of one nipple of two years' standing, followed by swelling, hardness of the breast, with retracting nipple. This increased for nine months, and then ulcerated. When seen there Avas an open cancerous ulcer of the breast and nipple. Her mother is said to have died from cancer of the face. Operation advised, but refused. Mental anxiety as a cause of carcinoma must not be omitted, although to adduce proof of the truth of the proposition may be dithcult ; to say that it is an antecedent of many cases of carcinoma is, however, a fact which the experience of most surgeons would support. The late Mr. Charles Moore was a firm believer in its influence. lyo Diseases of the Breast. [Chap. xii. On tlie influence of locality in cancer. — It is impossible to deny the influence of nationality and of geographical position upon the frequency o£ cancer. For in some countries little of it is seen^ whereas, in others, it is met with fi'equently in certain districts, and in others but rarely. In Turkey, Greece, Syria, Persia, North Africa, and Ice- land, it is very rare, whereas in parts of India and China it is more common. In Europe its relative frequency is very curious, and Hirsch tells us that it varies from nearly 10 cases in 10,000 inhabitants, as met vtdth at Trondlijem in Norway, and in Lombardy in Italy, to 2 in 10,000 in Sardinia. In America the death rate is about 4-5, and in England much the same, the rate apparently in our own land having increased during the last few decades ; that ending 1859 having been 3-3, and that ending 1876 4-6 per 10,000. In all these statistical figures it may be fairly assumed that in women half the cases are afiections of the breast and uterus. Lastly, as one of the causes of cancer, and conse- quently of cancer of the breast, is the geographical distribution of the disease. Dr. Haviland having demonstrated by means of a cancer chart collated from the records of the Hegistrar-General, and read before the Society of Arts in 1879, that there are certain localities in England in which cancer [)redominates largely over others, and he certainly has shown that these cancer fields lie along the low lying allu^'ial beds of river courses, and the geological strata of the tei-tiary formation. "Cancer fields," he wrote, "are situated along rivers that occasionally overflow their banks." Hirsch, however, is no believer in this theory or explanation, for he reminds us that in Norway, cancer occurs mostly in the mountainous districts, and at considerable elevations ; also that in Mexico the high table-land is more subject to cancer than the low places. Chap. XIII.] Carcinoma. lyt By way of summary as to the causes of carcinoma, the following conclusions seem just. 1. TJiat there exists in those who manifest the disease, and probably in many others who never live to do so, a predisposition to its development under any exciting cause. 2. That this predisposition is, to a degree, due to heredity, although sufficient evidence exists to suggest that the predisposition may he strengthened, or even acquired, either by long residence in low lying districts in which rivers are prone to overflow their banks, or by the long continued depressing effects of mental influences. 3. That the disease is, under all circumstances, primarily a local one, originating in a gland or tissue that has been the seat either of a direct injury, or that has imdergone some degenerative change, the effects either of age, obsolescence, or some antecedent spurious functional activity, inflammatory action, or persistent local irritation. CHAPTER XIII. THE CLIXICAL FEATURES OF A SCIRRHOUS CARCINOMA. When a cancerous tumour has fully developed, and more particularly the first two varieties, it has features of so marked a character that its nature can hardly be misunderstood. When it is developing, its early features are ill defined and uncertain, consequently a positive diagnosis of its nature is difficult if not im- possible ; and yet it is at the very early stage of the disease that a diagnosis is most essential, since it is 172 Diseases of the Breast. [Chap. xiii. then, if at all, tliat a cancer may be regarded as a local and consequently as a curable affection. It is to be remembered that in the majority of cases of carcinoma of the breast, the disease attacks the breasts of women about forty years of age when the procreative organs are verging towards their natural period of functional decline ; and when the breast as a gland is either obsolete, or is passing into the stage of obsolescence. It is, however, found in younger, as well as in older subjects ; when in the younger it usually appears as an acute or active affection, when in the latter, as a more chronic one. Early local symptoiiiis of carcinoma. — In the majority of cases when discovered it appears either as- an ill-defined thickening of one of the lobes of the gland, or as a nodular swelling fijced closely to the tissue of the breast. It is generally found out by accident, as in washing, and the attention of the patient is rarely drawn to the part by pain ; should pain be present it will generally show itself as an occasional shoot of pain, although sometimes as a sensation of heat. With these early symptoms present, how is a diag- nosis to be made ? for what affections may the disease be mistaken ? A few words upon these questions may be of value. Should the disease appear as a mere thickening of one of the lobes of the breast, this clinical fact is one, which of itself should excite the apprehensions of cancer ; for the thickening can only be brought about by one of two causes, either carcinomatous infiltration, or chronic inflammatory infiltration; and it must be admitted that too often to the touch these two forms of infiltration yield the same sensations. In cancer, however, in a large proportion of cases, the hardness is of a stony, unyielding character, and the examination, if not rougli, is well tolerated ; whilst in Chap. X 1 1 1 . ] Car cinoma . 173 the chronic inflammatory condition the induration is fleshy and somewhat yielding, the same amount of manipulation likewise evokes pain. In the chronic inflammatory trouble there will likewise probably be more pain on gentle manipulation than is usually met with in cancer, and after examination the patient will show some signs of excitement or irritability. In this latter trouble, also, more than one of the lobes of the gland will probably be found coarse and knotty, although but one may be tender, and possibly the opposite gland will be equally affected. In cancer, in brief, the disease starts in one lobe of a gland, and as an indolent swelling it is rarely associ- ated with any signs or symptoms of local inflammation, such as may be made out in the chronic lobular inflam- mation of the breast, which is prone to attack women at the climacteric period. Cancer in its early stage is known more by the absence of symptoms than by any- thing more detinite, by a painless, or nearly painless local, stony infiltration of a part. This stage of cancer may be described as the "early infiltrating stage." When the disea.se first shows itself as a nodular swel- ling fixed closely to the tissue of the breast, the same thought of carcinoma should be excited, but at the same time the possibility of the lump being due to the presence of an involution cyst should not be for- gotten. The rounder the lump, the greater the probability of its being cystic ; the more irregular and nodular the swelling, the greater the probability of its beinof cancerous. A hard, nodular swellinor is more likely to be cystic than inflammatory, and it is at least as likely to be cystic as cancerous. For diag- nosis an exploratory puncture with a needle is fre- quently demanded ; or what is better, an exj^loratory incision. As the disease advances, and reaches the stage which, for descriptive or clinical purposes, may well 174 Diseases of the Breast. [Chap. xiii. be called the " mature infiltrating stage," the diag- nostic points become more marked. The induration of the lobe primarily involved has become more evident, and it has probablv spread from its early position in a single lobe, either to a neighbouring lobe or to the soft parts covering in the lobe, and in this way changes will have been brought about in the skin, which are all equally characteristic, and differ only in the degree in which the skin with its subcutaneous tissues is involved. I have been in the habit of describing these changes, as will have been observed by the reader in perusing some of the pre- ceding chapters, under three headings, namely, " Dimpling,"' " Puckering," and " Infiltration " of the skin, and I believe that this division tends to clear- ness. Dinipliu^ of the skin means more or less de- pression or cupping of the skin covering the infil- trated lobe, brought about by the contraction of the suspensory ligaments of the breast (Plate I. Fig. 1), which pass from the normal capsule of the gland to the skin itself. Where only a few of the ligaments of the gland are involved^ the dimpling or cupping of the skin will be limited j where the ligaments involved are numerous, the area of skin depression will be extensive. This condition is well seen in Plate III. Pig. 1. Tlie skin at this stage can, however, be rolled over the growth beneath, or raised from it. This symptom is never present in any connective tissue tumour of the breast, nor in an inflammatory affection. The peicb-eriiig" of skin is a later stage than that described, for in it the skin is closely drawn down to the growth beneath, and has practically become a part of it by the process that has been described as local infection. {See Plate III. Pig. 2.) The suspensory ligaments have contracted to the Chap. X 1 1 1 . J O RCINOMA . I 7 5 full, and the skin can no longer be rolled over oi raised from the growth. The depression of the skin is now still more marked than it was in the *' dimpling " stage, and the surface of the skin presents to the eye a peculiar pitted apf)earanee, which Mr. Banks has aptly described resembling the pig skin of which a saddle is made. The skin, on manipulation, may feel, to the touch, fairly healthy, or it may seem slightly harder than normal. This condition being suggestive of the next or most diagnostic indication of carcinomatous disease (the stage of local "skin intiltration ") in which the skin has become involved by the extension of the disease, by local infection. In the infiltrating stag^e the skin is not only drawn down and puckered in the ways already de- scribed, but it is bound down to the growth beneath, and to the finger feels firm and indurated ; the indu- ration being brought about by the infiltration of the skin itself with carcinomatous elements. The tumour at this advanced stage of the disease seems to be one with the skin ; neither in the gland nor in the skin can the surgeon clearly define the boundary of the growth. In fact, it has no definite boundary ; for from its central lobular starting place the epithelial elements have spread by infiltration outwards in all directions, and drawn all surrounding tissues into its sphere. In some examples of disease at this stage of trouble the mobility of the tumour will have considerably lessened ; what could before have been moved freely with the breast gland upon the extended pectoral muscle, is now somewhat checked in its movements, in some cases to a limited, in others to a marked,- degree ; the degree of immobility of the tumour and breast gland upon the pectoral muscle below being the exact measure of the amount of infiltration of the deeper tissues^ in the same way as the " dimpling," 176 Diseases of the Breast. [Chap. xiii. " puckering," and " infiltration " of the skin is an exact measure of the infiltration of the superficial. To test the mobility of a breast tumour upon the pectoral muscle^ it is essential that the muscle should be placed upon the stretch by raising the arm. With the muscle relaxed, a tumour which is perfectly fixed to it may appear movable, the tumour and relaxed muscle moving together. With the muscle extended this fallacy will be avoided. Relraction of nipple in carciuonia of tlie l>r east.— There is no greater fallacy than the very general assumption that I'etraction of the nipple is an essential symptom of carcinoma of the breast ; and no greater error than that with this symptom the diagnosis of cancer is confirmed, and that without it the disease must be of another kind. The truth is that retraction of the nipple is only an accidental symptom of cancer of the breast, met with when the disease is placed near the nipple, but not otherwise ; that is, when the disease is so situated that the ducts of the gland are drawn upon by the infiltrating process, and the nipple, as a consequence, is pulled, as it were, towards the infiltrated lobe. When this retraction of the nipple exists associated with a chronic infiltrating tumour of the breast, it is, as a symptom, one of great value ; indeed, as great as the dimpling and puckering of the skin over the tumour has been shown to be (Plate III* Eig. 2), By itself the symptom is of no special value, since it may have been a congenital condition, or an acquired one from some antecedent inflammatory or other aflfection. Again, should the infiltrating lobule be placed at the periphery of the gland, where, by its contraction, the ducts of the gland, as they pass to the nipple, will be but little aflfected, there will be no retraction of the nipple. Indeed, the nipple may, under these circumstances, be very prominent. The symptom, therefore, is only of value when found in Chap XIII. ] Carcinoma. 177 combination with other symptoms ; by itself it tells nothing. Again, in some cases the nii)i)le may become retracted during the early stage of the disease, and at a later period become .])rominent ; the disease at an early period of its progress causing traction upon the lactiferous ducts, and at a later period of its course, by steady infiltration, so thickening the gland be- \ iieath the nij)ple, or the nipple itself, as mechani- cally to lift it out of its umbilical bed and cause it to project. In a third class of cases the nipple may become strangulated at its base by the con- traction of the carcinoma, and consequently oede- njatous, and possibly ul- cerated. At a still later stage, from the same cause, the nipple may slough off. At times a retracting nipple is the first point which draws the atten- tion of the patient to her breasts, and leads to the detection of an early carcinoma. One of the best examples of retracted nipple I have seen was in a woman past middle life, who had a central tumour of her breast (Fig. 4). The nipple seemed telescopically to be inverted, and to form a de- pression in the centre of a circumferentially raised lleshy growth. The tumour, when removed, turned out to be an adeno-sarcoma, develo^ied beneath the base of the nipple, in the centre of the breast gland. By its growth it had steadily made traction upon the ducts M— 25 Fie. 4.— Eetraction of the Nipple in case of Adeno-sarcoma of a woman, aged 54. ijS Diseases of the Breast. [Chop. xui. of tlie gland, and as a consequence drawn the nip[)le as described. Sim]:)le tumours, however, rarely cause this retraction. They may, by their growi:.h, flatten a nipple out, or push it into some out-of-the-way place, but they seldom cause its retraction. Where this symptom is present with a benign tumour, it is due either to the central position of the tumour, or to a congenital or acquired condition, such as a former abscess, or local inflammation. Discliarg^e from tlie uipple in cancer. — In the carcinoma fibrosum of the breast it is by no means common for the patient to comj^lain of any discharge from the nipple. In exceptional cases this symptom may exist, and in some cases before me a serous or blood-stained discharge had preceded the induration of the breast by some months. In one a serous discharge was the earliest symptom ; in another a bloody discharge had existed for six months before any tumour was discovered ; in a third case a blood- stained clear dischai'ge had existed for 2| years before a lump was detected ; in the fourth case there had been a porter-like discharge from the nipple for four years before a tumour was recognised. In all these cases, when they came under my care, the disease was clearly of the true scirrhous form, and unaccomjDanied with any marked cystic complication. In a general way, when there is much nipple discharge before any solid neoplasm is discovered, the disease has been cystic in its origin, and carcino- matous or sarcomatous secondarily. These cases will, however, receive attention in chapter xvi., which is devoted to cystic disease. In the following cases the growth of the tumour was preceded or accompanied by some discharge from the nipple : 1. Cancer of breast jrreceded by discharge from nipple. 'ane E., aged 35, the mother of three children, the CHap. XIII.] Carcinoma. 179 youngest being eight months old, and all of whom she suckled, came under my care on October 2Gth, 1867, Avith induration of her left breast, dimpling of the skin over the breast, retracted nipple for six months, and discharge of l)lood from the nijDple for five months. In January, 18G8, the discharge from the nipple had ceased for two weeks, but returned copiously. On September 3rd, 1868, the breast was much larger and harder ; the nipple had retracted more ; the skin was puckered and. infiltrated ; no axillary glands were enlarged. Operation w^as advised, but refused. On July loth, 1868, the arm was cedematous, and she was sinking. 2. Carcinoma of hreast v:ith iraperfect nipjjle, and early discharge from nipple; operation; recovery. — Sarah N., a married woman, aged 40, the mother of four children, all of whom she had suckled with her left breast, but not with her right, as the nipjjle was imperfect, came to me in August^ 1872, with a general infiltration of her right breast, retracted nipple, pucker- ing of the skin over the tumour, and enlarged lymphatic axillary glands. This disease had been coming on for four months, and attention was first drawn to it by the discharge of a curdy material from the nipple, which could be increased by pressure. The breast was removed and recovery followed. The tumour was of the scirrhous kind, with cystic elements. 3. Carcinoma of hreast ; bloody discharge from nipple; operation ; well four years kiter. — Mrs. G.,aged 60, no children, for 2\ years had blood-stained discharge from the nipple and some hardness of the left breast ; the discharge could be increased by pressure. January 28th, left mammary gland, nipple, and axillary lymph- atic gland infiltrated with carcinoma. All were r^ moved, and patient convalesced. The tumour was of the common scirrhous kind. Four years later this patient was well. i8o Diseases of the Breast. [Chap. xiii. 4. Scirrhous carcinomia of the breast., associated with discharge of porter-like fluid, from a retracted nipple, andfoUoiDed hy tuberculation of the skin and enlarged axillary glands ; excision of growth with glands ; re- turn of disease in skin and opjoosite breast ; j^atient was alive four years after operation, or eight years after its flrst ajypearaoice.—^lrs. W., a childless married woman, aged 46, came under my care in May, 1875, with her left breast and skin covering it wholly infil- trated with carcinomatous material, and enlarged axillary lymphatic glands. The disease had been slowly coming for four years, and had commenced as a glandular induration and some retraction of the nipple, the nipple soon discharging freely some porter- like fluid. I excised the breast with the skin over it, and the axillary glands, and a good convalescence followed. Three years later some few tubercles appeared about the scar, and these slowly multiplied. In January, 1882, the opposite breast became involved, but the patient's health was good. I- then lost sight of her. The disease had existed for eight years when I last saw her, aud the breast had been removed four years previously. " Ln not explicable by either of these methods, can only be explained by either the appearance of a fresh focus, or by a dissemination of the local disease by a more obscure local or lymphatic infection. Cases mifit for operation. — An operation on the breast, as in other cases, may be inexpedient from either local or constitutional causes. Cases in which the disease cannot be entirely removed should be left alone ; as well as those in which the disease can be wholly removed, but the patient, either from age or general condition, induced by any cause, is too feeble to undergo the ordeal of an operation. Locally, tumours that are fixed firmly to the pectoral muscle and parts beneath ; tumours compli- cated with lymphatic glandular troubles which cannot be eradicated, more especially enlarged glands above the clavicle ; tumours associated with oedema of the arm on the affec+ed side, as well as those with secondary external or internal metastatic growths, are not to be interfered with. Cases of brawny carcinoma had better not be touched ; nor had those of atrophying scirrhous or other varieties of the disease which are associated with the presence of tubercles more or less diffused about the skiiL Cancer en cuirasse should never be interfered with. To gain a good idea of the effects of operation in cancer of the breast upon the duration of life, a statistical comparison of the two classes of cases, that Chap. XIV.] Treatment of Carcinoma, 219 is of those operated upon and those left alone, must be made. In a former page (l-'52) I gave a table of my own, showing the results of operation, and compared it with a second of Sir J. Paget, composed of cases in which no operation was performed. I give here Gross's statistics upon the same question, he being the most recent writer upon the breast. I have embodied his conclusions in the following table, which tells strongly in favour of operation : Died in hetween 5 and 12 months. 12 M 24 24 „ 36 36 „ 48 4S „ 60 00 „ 72 ,, After 6 years Average duration of life, (1 year being added to life by the operation). Not operated Operated upon. upou. 30-8 p.c. 10-5 p.c. 37-7 „ 33- „ 11-3 „ 24- „ 9-8 „ 9-9 „ 7-9 „ 7-9 „ 3-4 „ 5- „ 1-2 „ 9-5 „ 27 months. 39 months. Velpeau stated in 1864, at the French Academy of Medicine, that out of 250 cases in which patients had survived the operation of amputation of the breast, twenty, or one in twelve and a half, had re- mained free from disease for more than five years, some few having been so for ten or twenty ; and these operations must have been what would now be called incomi)lete operations, for before and at the date named the lymphatic glands were rarely touched. Nunn likewise states that one case in thirteen on an average lasts from ten to twenty years. Compared with these results, my own table is very favourable, for at least one-fourth of the cases lived from five to ten years or more. But it must be re- membered that in at least a third of these cases the 2 20 Diseases of the Breast. [Chap. xiv. major operation of tlie complete removal of tlie breast and lymphatic glands was carried out, I have been nnable to make fixm my own cases, as Gross lias made from bis, a com23arison between cases that bare been operated upon, and those that have run their natural course, the difficulties of tracing patients who have not been submitted to operative treatment being greater than in those who have. My own table of operative cases, however, fairly supports Gross in showing the good effects of operation, and I think more forcibly, for in mine at least 14 per cent, lived over six years against his 9 '5 per cent., and 25 per cent, lived over five years against his 14-5 per cent. Life is therefore probably prolonged by oj)eration, and more particularly by what must be described as a complete operation ; indeed, by such a measure, even where it includes the removal of the cancerous breast, with its infected lymphatic glands, a permanent recovery may, in a certain proportion of cases, be looked for. In what exact proportion of cases this result can be secured, it is difficult to say, but if we adoj >t Gro.ss's method, and assume that when a patient has survived an operation over three years without any local sign or general indication of recurrence, she may be pronounced cured, I do not think his pro- portion of 9 per cent, of all cases is too high. Recur- rence may, however, take place at a date long after tkree years, consequently Gross's view can only be an average one. At page 158 a case is recorded in which, after operation, no recurrence took place for twenty-five years, and on looking over my notes I read the case of a woman, aged 47, who was operated upon after the local disease had existed for two years, who remained well for five years when a local recurrence took place, and a second operation was performed ; the second Chop. XIV.] Treatment OF Carcinoma. 221 operation being followed, after the lapse of another five years, with a second recurrence which rapidly grew and destroyed life. Case 2 was that of a woman, aged 50, who, after having been operated upon for a disease of two years' standing, remained well for eleven years ; then a local return of her trouble appeared, which was removed, and two years later she was well. Case 3, a patient of Mr. Birkett's, who had her breast removed in 1851, when 67 years of age; she remained well for twenty-three years, and at the age of eighty had cancer of the scar and oj)posite breast. Case 4, also a patient of Mr. Birkett's, who had her breast removed at the age of 30 ; thirteen years later the disease recurred in the scar, when a second operation was performed. Two years later a second recurrence was followed by a tEird operation, and there the record stops. Case 5. In 1876 I removed the right breast of a woman, aged 48, for carcinoma, with a good result, from whom ^Ir. Hilton had, ten years before, in 186G, removed the left breast for the same disease. In neither operation were the axillary glands felt enlarged, nor looked for by an exploratory operation. In lo79 the woman was well. Gross gives, moreover, a table of forty-seven cases which he regarded as cured. 14 of these had been free from disease after ope- ration for 3 years and some months. 18 had been well from 4 to 6 years and some months. 7 „ ., 6 to 9' „ ,, 5 „ ., 9 to 12 „ ., 3 „ „ 12 to 15 „ „ The average time of cure was five years and nino months, and the disease had existed before operation on an average of eighteen months. 2 22 Diseases of the B feast. [Chap. xiv. Mitchell Banks * more recently has given us a table of complete operations in which the primary- tumour and lymphatic glands were freely removed. Seventeen out of sixty-four cases are reported to have been alive, and to have remained free from the disease for three years and upwards, five having been well from three to four years ; three from four to five years ; three from five to six years ; two for six years ; two for eight years j one for twelve years ; and one for thirteen years. Tliis advantage of operation is further seen when it is undertaken early. That a woman would have a better chance of gaining the full advantage of an operation for cancer when it . is performed before lymphatic infection has taken place, is only what might be expected.; the facts of Winiwarter and Oldekop partly prove this to be the case. " Thus, of 136 patients subjected to operation, 43, or 31 percent., were free from glandular complication, and their average duration of life from the first observation of the dis- ease to the fatal issue was 52-7 months; whereas of the ninety-three cases in which the lymphatic glands were enlarged and removed with the breast by opera- tion, the average duration of life was only 39*3 months, or 13 "4 months less than the more favoured class. In the uncomplicated cases recurrence of the growth ave- raged eight months, in the complicated 1*9 months." The major or more complete oj^erative measures appar- ently have done little or nothing in the way of post- poning recurrence of the disease. Gross adds that nearly one-third of the patients who had been subjected to the radical operation were free from disease after the lapse of six years, while of the patients in whom no operation was practised only one survived that period. liocal recioTence after operation. — That * Harveian Society ; March 3, 1887. Chap. XIV.] IrEATMENT OF CARCINOMA. 223 this is to be expected general experience justilies, but at what period it may be looked for is most uncertain. Gross reports that of 368 patients operated upon, all but seventy-two had recurrences ; that is, in four cases out of five recurrence is to be looked for. It would have been interesting to know in how many of these 368 cases the com])lete operation had been carried out. Winiwarter and 01deko|) go further, and by an analysis of 203 cases demonstrate that : 4th „ 6th 6th „ 9th 9th „ 12th 13th „ 18th 19th „ 24th 2oth „ 30th 31st „ 36th In 39 cases it occurred within 15 ,, 50 ,, ,, 1 month. ,, 38 „ between the 1st and 4th month. )) 18 „ „ » 1<3 „ 19 „ 9 „ 6 11 "^ 11 11 11 3 ,, 2 after 3 years. Erom this table it is evident that in more than half the cases a recurrence takes place within three months of the operation ; in a quarter of the cases re- currence may be looked for between three and twelve months ; whereas in the remaining fourth the recur- rence may be looked for at any time during the three years. After this time it is not to be expected, and it is to be hoped that the patient may be regarded as cured. The longer the interval between the primary ope- ration and the so-called recurrence, the better the prog- nosis. The surgeon should always look upon cases of so-called recurrence within three months as probable instances in which some portion of the growth, or some of the lymphatic glands had been left behind ; in fact, he should regard them as examples of con- tinued grow^th of some overlooked carcinomatous centre. 2 24 Diseases of the Breast. [Chap.xiv. When a cancerous breast is alone remo^^ecl, writes Gross, recurrence is to be expected on an a^-erage of 3-1 months; when it, with diseased axillary glands, is taken away, that is, when what is called the complete operation is performed, recurrence of disease averages 7*5 months; the more severe or complete operation apparently not doing much more than postpone recur- rence for a few months. It would seem fi'om Winiwarter, Oldekop, and Henry's statistics, that half the patients that die from cancer do so from metastatic deposits, whilst the other half die from the baneful effects exerted upon the nutrition of the patient without cancerous degenera- tion of the viscera. These authors compute the average date of death from metastasis from the first appearance of the disease at 31-2 months, or fifteen months after lymphatic infection ; metastasis may occur from five months to eight years. Metastatic deposits.— To demonstrate the re- lative frequency of the seats of secondary deposits, Gross has compiled a table from his own cases, added to those of Arnott, Henry Morris, and Clark, pub- lished in the 27th volume of the Transactions of the Pathological Society of London, p. 264, in this w^ay tabulating 128 post-mortem examinations, from an analysis of v/hich he shows that secondary tumours were found in the Per cent. Avillary glands in 115 cases or 89- Other ;> 30 jj 23- Lung »> 28 M 22 1 ,x 23 P^ Pleura 30 Pericardium )5 3 J> 2-3 PeritonEeum 3 )> 2-3 Brain ., 3 2-3 CEsophagus J5 1 ,, 0-78 Stomach. 5 3-9 Jejunum . 1 >J 0-78 Chap. XIV.] Carcinoma. Per cent Liver glands in 55 cases or 43- Pancreas ,, 1 „ 0-78 Spleen 3 2-3 Kidney 5 3-9 Adi^eual 2 „ 1-5 Ovary 7 5-4 Uterus 2 „ 15 Bladder 1 0-78 Bones 9 7-0 Muscles , 2 „ 1-5 225 He then concludes that when left to itself, carcinoma inevitably kills by its baneful consequences as a local disease, or by its remote multii^lication. That about one in six, or 16-7 per cent., of the patients die of the operation itself, but that the risk is not so great as to forbid interference, since it adds twelve months to the life of the patient. That thorough operations definitely cure 9 per cent. of all patients, or more than half as many more as it destroys. That the patient is safe from reproduction if three years have elapsed since the operation, and that, finally, recurrence may be delayed for several months, or be prevented altogether, by clearing out the axilla at the same time that the entire breast is removed. Gross maintains, moreover, that the proper measure is to remove the entire breast and its coverings by a circular incision, search for any outlying lobules that may be disseminated throughout the mammary region, dissect off the fascia of the pectoral muscle, and pro- long the outer portion of the incision into the axilla, with a view to its thorough exploration. "Expe- rience shows, first, that the seats of recurrence, or rather farther spread of the disease after operation, are the skin, paramammary fat, remains of the mamma, and glands of the axilla ; and, secondly, that recurrence in the axilla is far more frequent p— 25 226 Diseases of the Breast. [Chap. xiv. after removal of tlie breast alone than when that cavity was freed of its contents simultaneously with the extirpation of the breast. That excision of the breast, with the axillary lym- phatic glands, is a giaver operation than excision of the breast alone, is what might be expected. Thus, an analysis of cases made by Dr. Stettegart* shows that of 264: cases in which the T3reast and axillary glands were removed, 61 cases, or 23 per cent., died ; while of 130 cases in which the breast alone was removed, 10 cases, or 7*7 per cent., died, the mortality of the complete operations being three times as great as of the incomplete. This mortality, moreover, is e\T.dently relatively greater, since it must be admitted that the complete method of operating in breast cases has only come into vogue during the last few years, when the treat- ment of wounds g'enerally has been far more successful than it was in previous years. The question before us consequently is evidently this : Can the more severe operations on an average show either a definitely longer interval from recur- rence, or a larger proportion of substantial cures % If experience can answer either of these questions in the affirmative, the surgeon is then justified in submitting his patient to the graver ordeal ; if otherwise, is this the case 1 As regards the recurrence of the disease after operation, Gross has shown that whilst in the minor measure of removal of the breast it is to be looked for on an average in about three months, in what is called the complete method it ensues in about seven and a half months. He, however, at the same time, believes he has shown that Kfe is prolonged by this operation about one year. In my own practice I have not, as a matter of * Lan^enbeck's Archives, Bd. xxiv. ; 1879. ciiap. XIV.] Carcinoma. 227 routine, exi)]ored every axilla for enlarged lynipliatic glands, and particularly in thin women, in whom, under an antpsthetic, the condition of the axillary glands can fairly be ascertained by maiiipulation. I have, however, always done so when enlarged glands could be made out, and when manipulation was dilHcult and its conclusions uncertain. I have had no reason to find fault with the results of my practice. Out of 56 complete operations, private and public, performed, with all the advantages of improved wound treatment, I have lost 4, or 1 in every 14 cases, or 7 per cent. ; whereas, on referring to former times, when the condition of the axillary glands was only surgically considered when their enlargement was manifest, and wound treatment was as a whole less successful, I lost 8 out of 120 cases, or 1 in 15 cases, or ^-^ per cent. It is true that the causes of death in both classes of cases can in a measure be explained away, and evidence brought forward to suggest that the opera- tion in at least half the cases had little or nothing to do with the result. I have no intention, however, to do this, as the ultimate issue of the question must turn upon the main facts. Could a carcinomatous tumour always be removed in its early infiltrating stage, that is, when the disease is local, cures may be hoped for. When it is taken away after it has ad- vanced and spread by lymphatic infection, the chances of a complete cure are remote. Other things being equal, free excision is more likely to cure. But are they equal if the mortality of the complete measure is in excess % When this operation of removal is called for, it should, therefore, as a rule, be complete ; that is, not only the tumour should be removed, but the whole mammary gland in which it is placed ; with all affected or possibly affected skin and fat about it j but the 2 28 Diseases of the Breast. [Chap. xiv. practice of exploring an axilla as a measure of routine should not be followed, since it is without doubt a graver measure to the patient, and the advantage which it in theory possesses is not yet proved. The removal of a breast for cancer is often expe- dient and necessary for purposes of relief rather than of cure ; and a breast may often be removed with this object when the exploration of the axilla is neither called for nor justifiable. The surgeon's judg- ment in this matter is wanted in each case as it may come before him, and he is not to be governed by a dogmatic rule which experience soon proves is not a safe one. A series of cases could readily be given by one surgeon to show the advantages of the complete measure ; whilst another, or possibly the same sur- geon, could give another series equally striking, to demonstrate the value of the so-called incomplete. A measure which is right and justifiable in one case may be wrong and unjustifiable in another. An operation which offers a prospect of cure, and removes what is a source of mental and bodily worry, should always be performed in preference to any partial measure, unless the general condition of the patient is such as to lead the surgeon to believe that any extra risk is incapable of being borne with safety. The advantages of the graver operation are not, however, so certain as to justify increased hazard to life. On excision of tlie breast. — There is, in average cases, no great danger attending excision of the breast beyond that which accompanies any, even the smallest, operation. In feeble and aged subjects there is, however, much risk, and a certain proportion of cases may be expected to sink after the operation from pyaemia, erysipelas, or visceral disease, since these contingencies attend any operation or wound. From my notes of hospital operations on the breast for cancer, Chap. XIV.] Excision of Breast. 229 or rather of 200 consecutive cases, only 10 died from pyaemia, pneumonia, or erysipelas, the mortality being but five per cent., and these causes are yearly dimin- ishing. Out of 176 cases in my own practice the mortality was 12, or 7 per cent. Gross gives a mortality of 16 per cent. In operating for cancer it is unquestionably the wisest course to excise the whole gland. It is well not to be over-anxious about preserving too much in- tegument, and if any doubt exists as to its perfect healthiness the suspected portion had better be ex- cised. "When enlarged lymphatic glands clearly exist they should be taken away, and in most otlier cases where their existence is suspected the axilla should be explored. It is always important, when dissecting out the tumour, to keep clear of all diseased tissues, and, in fat subjects, to take away much of the fat, since there is good reason to believe that an early return of the affec- tion is too often to be explained by want of attention to these points. When the pectoral muscle is infiltrated it must be freely excised. The pectoral fascia should be closely inspected, since in it small cancerous nodules are often found, which, if left, would have been the centre of new growths. The operation. — In the removal of a breast the patient should be placed on her back with the shoulder of the affected side raised by a pillow, and the arm drawn out at a right angle to the body. The incision should be elliptical, and made in a line parallel Avith the fibres of the pectoral muscle. When the skin is diseased and has to be removed, the incision may have to be circular, and bleeding is to be controlled by the pressure of the fingers of an assistant, or by torsion. The outer or pectoral inci- sion should first be made, and carried well doA\Ti to the free border of the pectoral muscle, the definite form of which is the best and surest guide to the 230 Diseases of the Breast. [Chap. XIV. base of the gland. The inner or sternal incision may then follow. The whole tumour should then be ex- cised and dissected away, a few touches of the scalpel clearing it off the pectoral muscle. The axillary angle of the tumour should be divided last, as it usually Fig. 6.— Excision of the Breast. contains the lymphatic cords and chief vessels that supply the gland. The incision can be extended up- wards into the axilla along these cords to explore or remove the glands. When this is done an incision at right angles to the wound backwards is good for drainage purposes (Fig. 6). All bleeding vessels should be twisted, the surface of the, wound cleaned with iodine water (5ii. ad Oi.), carbolic acid lotion (5iv. ad Oi.), bichloride of mercury (gr. x. adOi.), or chloride of zinc (gr. xx. ad^i.), its edges well adjusted, a drainage tube introduced at the most Chap. XIV.] Excision OF Breast. 231 dependent part, and steady pressure applied by means of pads of antiseptic lint, gauze, or cotton wool, the wound being treated on ordinary pri"nciples. The axillary glands should be removed more by enucleation with the fingers and a blunt dissector than by the knife ; by care and a little patience this may usually be accomplished with safety. The surgeon must be careful not to draw too much upon the axillary mass where such exists, for by so doing he will probably drag the large vessels, and more particularly the veins, out of their position, and ex- pose them to injury. All pai-ts that are cut through should be ligatured first, and then divided in the distal side of the ligature. Banks advises that the axillary vein should be first exposed, after which no danger of wounding it will be experienced. Should the vein be wounded it should be tied. Beyond satisfying myself that the drainage of the wound is satisfactory, I rarely remove the first dress- ing for three days, when, in favourable cases, what i:)art of the wound was' wanted to heal by quick union, has repaired, and the open surface is granulating. This I wash with iodine water, and dress with lint or iodoform gauze, soaked in a mixture of one part terebene and three parts olive oil, covering in tlie whole with a sheet of Gamgee tissue. By these simple measures repair is carried out. The essential point the surgeon has to observe in the operation is thoroughness ; with this, success may be hoped for and reasonably expected ; without it failure and disappointment must be the result. Inadequate and too late operations have doubtless been the cause of many of our failures, and these again explain why it is that some practitioners refrain from advising operative interference, and consequently prevent their patients from seeking early surgical help. , 232 Diseases of the Breast. [Chap. xiv. When the profession, as a body, is led to look upon cancer of the breast in its origin as a local disease, and consequently one to be treated early ; when surgeons are bold enough to advise, in early doubtful cases, an exploratory incision into the growth with a view to its excision should the disease be found to be carcinomatous, better results will be obtained. Excision is likely to be most suc- cessful when applied in the stage which precedes that of lymphatic infection, and when the cancer may be regarded as a local affection. Those who come after us will doubtless have to record better and more encouraging results than I can adduce in these pages. On tlie treatJiient toy caustics. — This form of treatment has its pla-ce in surgery, but it is not to be considered in competition with excision, since by excision alone can the whole disease be taken away with the greatest certainty, and in the shortest possible time. Caustics are, however, useful in open cancerous ulcers, that camiot be excised, with the view of checking growth, preventing foetor, lessening discharge, and diminishing haemorrhage. A paste consisting of one ounce of a liquid extract of the sanguinaria canadensis, made by boiling down a decoction of the root, in which the same quantity of the chloride of zinc is dissolved, and then mixed with two ounces of the extract of stramonium, is very good ; and so is the paste used at the Middlesex Hospital, made by mixing chloride of zinc and boiled starch with laudanum, till it reaches the consistence of honey. At the Middlesex Hospital, where this method of treatment is practised more frequently than elsewhere, Mr. H. Morris tells me it is carried out as follows : The whole cutaneous surface of the breast to be removed is first destroyed by the action of fuming Chap. XIV.] Treatment OF Carcinoma. 233 nitric acid applied by a glass brush ; and in doing tliis, care is called for to guard against the effects of any running of the acid over the surrounding parts bj'' the application of some grease, and having at hand an alkaline lotion to neutralise the acid. When the skin has been destroyed, as indicated by its parchment-like feel and bloodless aspect, multiple incisions well into its substance should be made radiating from the nipple ; the surgeon taking care not to cut so deeply as to draw blood. Into the furrows thus made in the dead skin Rtri|)s of finely prepared lint should then be pressed, the caustic paste having been previously spread upon and well pressed into its meshes, and all redundant paste scraped off; the object of this being to prevent the paste running over healthy tissue and causing distress. The breast should then be covered with cotton wool and a bandage. In a day or two^ when the caustic has done its work, the strips of caustic lint should be removed, the furrows in the breast deepened by fresh incisions^ and strips of lint, prepared as before, a])plied. The same care being observed by the surgeon in his incisions not to draw blood. By a repetition of this process every two or three days a breast may be removed in about three or four weeks, and, it is said, with but little pain. Upon this point I am unable to speak from experience, as I have never removed a whole breast by this means. In some cases, painting an ulcerated surface over with liquefied carbolic acid is of great value, the acid acting as a caustic, disinfector, and anaesthetic at the same time. Of late years Esmarch's powder has been much advocated, and I think with justice. It is said to be painless. It is made by mixing one drachm of arse- nious acid with the same quantity of sulphate of 234 Diseases of the Breast. fChap. xiv. morpliia, eight drachms of calomel, and six ounces of powdered gum arabic. The surface of the sore is to be thickly sprinkled daily with this powder till a crust forms, and repeated if necessary. As an ordinary application to a cancerous sore where these severe caustics are not employed, I find an ointment made of two drachms of resorcin with six of vaseline is very good. I have thought that it dissolved the. epithelial structures, and consequently tended towards a cure. I have, in a few cases, used resorcin as a powder, dusted over a cancerous surface, and with advantage. I have thought it tended to bring about its disintegration. Injections of acetic acid into cancerous growths cannot be said to be quite useless, since, in one case already quoted (page 216) the injections brought the mass away ; but their effects are so uncertain and un- satisfactory, that they are not to be relied upon, and by their use valuable time is lost. When no local treatment of any special character is employed, and the disease must be left to take its course, pain must be assuaged by the internal or hypodermic use of morphia in one of its forms, the bimeconate being the best ; or the local application of a drachm of the extract of belladonna, rubbed down with one ounce of glycerine, or of the extract of stramo- nium ; or of an ointment containing a tenth part of cocaine. As a jDainless deodoriser. Gross speaks highly of a mixture of five grains of chloral hydrate to one ounce of vaseline. Should great activity be displayed in the local disease as indicated by extreme capillary injection and warmth, the local use of cold gives comfort and checks gi^owth. This may be eflected by means of one of Leiter's metallic coils or ice bags, and when these are inapplicable, by the employment of the usual lead lotion mixed with opium. Chap. XV.] Carcinoma. 235 In fou] cancerous ulcers a powder of fine iodoform or iodol mixed with boracic acid, in the proportion of one to four, is to be recommended ; and in very painful sores cocaine used as an ointment or in solution, of about half a drachm or drachm to an ounce, gives comfort. Hamamelis has been strongly advocated as an application to open cancer. I have, however, failed to find its advantages. SJiould local bleeding occur, a pledget of lint, soaked in a concentrated solution of alum, or of dried cotton wool which has been steeped in a solution of the perchloride of iron, will probably suffice to check it. The glycerine of tannic acid, applied on lint, is also under these circumstances useful. CHAPTER XY. A SERIES OF CASES ILLUSTRATING THE CLINICAL SYMPTOMS AND TREATMENT OF CARCINOMA OF THE BREAST. EACH CASE ILLUSTRATES A POINT. 1. Carcinoma of the breast, unrecognised in its early infiltrating stage ; subsequent excision and recovery. — Mary A. C, a healthy looking single servant, aged 37, came under my care on March 31st, 1877, with some swelling of her left breast. Her mother, maternal grandmother, and aunt all died of cancer of the womb ; father alive and well. For three months she had had shooting pains in her left breast, and for one month had noticed that it had become hard and tender. She thought also the nipple was retracting. When I saw her, one lobe of the gland was certainly 236 Diseases of the Breast. [Chap. xv. slightly fuller and liarder than the other ; it was like- wise very tender to the touch. The nijiple was not to any degree more retracted than that of the opposite breast. The skin over the breast was natural, and the axillary glands free. I was disposed to look upon the case as one of irritable mamma, and treated it accordingly. In a year she reappeared with a typical carcinomatous tumour, as indicated by a hard nodu- lated swelling in the position of the former tender and slightly hardened lobe ; adherent puckered skin over the tumour, well-marked retracted nipple, and enlarged axillary glands. I then removed the breast, tumour, and axillary glands, and a good convalescence followed. Four years later this patient was well. Remar'ks. — In this case an exploratory incision into the growth when first seen would have saved delay and a surgical error, although the subsequent progress of the case has been one of hope. It tends likewise to support the practice of making an exploratory incision into any doubtful tumour of the breast when first coming under observation. 2. Carcinomatous tumour attached to margioi of breast, simulating adenoma; excision of tumour ; patient well three years subsequently. — Catherine C, a married woman, 33 years of age, the mother of five children, came under my care in June, 1874, with a tumour in her. left breast, which had appeared six months pre- viously, when she had given up suckling her last child. The tumour had grown slowly since, and when seen was the size of a hen's Qgg. It was situated at the sternal margin of the left breast, and was hard, nodulated, and very movable. The skin over the tumour was free and natural ; the nipple was normal ; axillary glands natural. The growth was regarded as an adeno-fibroma and removed, the breast itself being left. A good recovery followed the operation. Chap. XV.] Carcinoma. 237 and the patient was well three years subsequently. A section of the tumour, and a careful examination of its structure, proved that it was an example of scirrhous carcinoma. I regretted at the time that the whole breast had not been taken away. The last report of her case was, however, that she was well three years later, and under such circumstances the feeling of regret has disappeared. The tumour must have been, when removed, a local disease. 3. Carcinoma of hreast ; dimpling of skin ; excision of growth ; recovery. — Mary A. T., a healthy looking, childless, married woman, aged 30, came under my care on April 11th, 1881, with some thickening of the clavicular lobe of her left breast, which had been coming on for four months, after a blow. The tumour was ill defined and firm, but not so hard as scirrhus generally is ; indeed, from its hardness alone no diagnosis could be made, particularly as the nipple was natural and there were no enlarged axillary glands. The skin over the tumour was, however, slightly dimpled ; with this symptom the diagnosis was made, and the breast and tumour first incised and then excised. The disease was clearly on section carcinomatous. A good recovery followed. In this case the value of the dimpling of the skin over a doubtful tumour was well displayed, since it enabled a definite diagnosis to be made as to the nature of the growth, and active treatment to be based upon it. Had this dimpling not ex- isted, an exploratory incision into the tumour, for diagnostic purposes, would have been called for, prior to its excision. 4. Carcinoma of breast ; painless j)rogress ; tumour and dimjjling of skin ; nipple natural ; operation and recovery. — Susan Y., a childless married woman, aged 58, came under my care in April, 1873, with a hard. 8 Diseases of the Breast. [Chap. xv. nodulated tumour of the upper segment of the right breast, about 2^ inches in diameter, which had been slowly growing for two and a half years, and abso- lutely without pain. The nipple of the gland was natural ; the axillary glands were not enlarged, but the skin over the tumour was dimpled. The breast and tumour were excised, and a good recovery ensued. 5. Carcinoma of breast aoid axillary glands ; shin over tumour and nijjple natural ; excision of disease ; recovery ; five years later the patient loas ivell. — Eliza H., aged 42, the mother of four children, all of whom she suckled without trouble, came under my care on March 14th, 1872, with a tumour the size and shape of a small orange, in the axillary border of her left breast, and a mass of enlarged axillary glands beneath the anterior border of the pectoral muscle. The tumour and breast moved freely over the parts be- neath ; the skin over the tumour was normal and quite free ; the nipple was natural. On March 22nd the breast was removed and the axilla was cleared out. Recovery followed, the woman being well five years subsequently. 6. Carcinoma of the breast ; attention drawn to part by retracting nipple, not from pain ; operation. — Eliza J., a thin, healthy looking woman, aged 60, the mother of six children, came under my care on January 6th, 1883, for a tumour in her left breast. She had had no pain, or even discomfort, in her breast, and her attention was first drawn to it by a nurse who, when dressing her, observed that the nipple was retracting. This led her to see her medical man, who sent her to me, when I found a small typical carcinoma fibrosum, as indicated ' by a stony nodular infiltration of the whole breast, with retracted nipple, and puckered integument over the tumour. The lym- phatic glands were not involved. As the patient was Chap, xv.i Carcinoma. 239 thin, and apparently a good subject for an operation, and the disease seemed to be quite local, I excised the gland, and a good recovery followed. The axilla was not explored. The patient was seen eighteen months later, and she was well. 7. Carcinoma attacking breast at the seat of an old abscess; nipple retracted; skin and lymphatic glands un- involved ; operation ; recovery. — Emma C, aged 59, the mother of two children (the youngest twenty-eight years of age) came under my care on May 17th, 1880, with a tumour in her left breast. When suckling her last child, twenty-eight years previously, she had an abscess in her left breast. Eight months ago she found a lump situated in the breast beneath the scar of the old abscess, and this lump has steadily increased, although without pain. At present there is a hard, nodulated sw^elling, the size of an orange, upon the upper and sternal segment of the left breast. The tumour is clearly in the gland, which moves with it over the deep parts. The skin over the tumour is healthy and movable, except where the old scar of the abscess exists. The nipple is much retracted ; the lymphatic glands are apparently uninvolved. May 21, the breast and tumour were removed, and a good recovery followed. The tumour was a good specimen of carcinoma. I have been unable to trace the later history of this case. 8. A carcinomatous tumour attached to the iipper border of right breast following a blow ; excision of tu- mour ; patient well four years later. — Eleanor C, a child- less widow, aged 40, came under my care in March, 1874, with a tumour four inches square, attached apparently to the upper margin of the right breast, although not in the breast, which seemed quite normal in all ways. The tumour had been growing for thirteen months, and had followed a blow received one month pre- viously. It had grown slowly, and when seen was 2 40 Diseases of the Breast, [chap. xv. somewliat fixed, altliough movable upon the parts beneath ; the skin over it was infiltrated, red, smooth, and j)art of the tumour. The axillary glands were free. On March 17th I excised the tumour and skin over it, lea^dng the breast, which did not seem to be involved. A good recovery followed, and four years later tliis patient was still well. 9. Carcinoma of left breast ; sloughing ; operation and removal of axillary glands ; relief — Mary B. J., aged 55, the mother of two children, came under my care on October 3rd, 1883, with a large fungating, bleeding, carcinomatous growth, involving the nipple and the whole of the left breast ; also the axillary glands. It was movable upon the deeper structures. The disease had existed for six years, had grown slowly for five, more rapidly for one. Nine months before admission into Guy's Hospital it began to break down, and for three months it had bled. On October 9th I removed the whole mass, with the axillary glands, and a good convalescence followed. Some months later she was well, and had greatly improved in her general condition. 10. Carcinoma of both breasts ; excision of both at an interval of two and a half years ; convalescence. — Harriet W., aged 60, a governess, came under my care in March, 1884, with a well-marked carcinoma of her left breast, of eight months' standing. It was the size of a walnut, and was placed on the axillary lobe of the gland. It was movable over the deep parts, and the skin over it was neither fixed nor dimpled. The nipple was retracted ; axillary glands free. Two and a half years previously she had lost her right breast for an open cancer of many months' standing. On March 28th I removed the tumour and breast, and a good recovery followed. The breast had almost disaj^peared by atrophy. 11. Carcinoma of the breast, axillary glands, Chap. XV.] Carcinoma. 241 skin, with discharge from nipple ; operation ; recovery. — Maiy M., a married woman, aged 48, the mother of three children, all of wliom she had suckled, caine under my care in September, 1874. Her grand- mother had died of tumour of her breast at the age of 79. Her mother was alive and well. The patient had discovered a lump in her right breast about one year before admission, and at the same time a swelling in her right arm-pit. There was no pain in either swelling for some months, but for about six months pain ap})eared as the swellings increased in size. When seen there was a dense, hard, nodular swelling in the upper half of her right, breast. The skin over the swelling was pitted like the rind of an orange, and adherent to the tumour beneath. The nipple was drawn inwards, and on pressure over the tumour a clear brown fluid exuded from the nipple, which,- when tested, was highly albuminous. In the skin above the tumour was a single, red, hard tubercle, which the patient said had followed a poultice ; the axillary glands were enlarged, but movable. On October 6 the tumour with the breast, skin over it, and axillary glands, were removed, a good re- covery following. Sixteen months later the woman was well. The tumour was a good example of scirrhous cancer. 12. EapicVy groiving tuberous carcinoma of the hreast icith all the well-marked symptoms ; operation ; recovery. — Emma P., a healthy looking woman, aged 39, the mother of four children, all of whom she suckled without trouble, came under my care on March 12, 1879, with a hard, nodulated tumour, measuring five inches by three, in the outer side of her right breast, to which the skin over it was attached by infiltration. The nipple was likewise retracted, and the axillary lymphatic glands enlarged. The tumour was first discovered only three montlis before, when it was the Q— 25 2 42 Diseases of the Breast. [Chap, xv. size of a walnut, the breast and nipple at that time appearing to be otherwise natural. On March 18 the breast tumour and axillary glands were cleared away, the patient making a good recovery. The specimen removed was an excellent example of rapidly growing soft cancer. It was soft, highly vascular, and lobulated, although clearly in- filtrating the breast structure. No subsequent history of this case can be obtained. 1 3. Carcinoma of the breast ; slow, and later on, rapid growth ; radical treatment with good result. — Mary M., aged 57, the mother of eight children, the youngest being 20 years of age, came under my care in April, 1876, with a hard, nodular tumour, measuring four by five inches in diameter on the outer and lower segments of her right breast. The skin over the tumour was "puckered," the nipple retracted, and the axillary lymphatic glands enlarged. The tumour had been growing for nearly three years, although for two and a half years its increase had been slow ; since then it has grown rapidly. At first it was the seat of occasional pain ; for the last six months the pain has been acute. The nipple was unafiected up to three months ago, when it began to retract ; at the same time the skin over the tumour became dimpled, and later on puckered to the parts beneath. The axillary glands became likewise afifected. On May 2 the tumour, with the breast and axillary glands, were cleared aAvay, and a good result followed. The patient was well a year later. The history of this case illustrates two diflerent conditions. The first one of slow and inactive growth ; the second of ra[)id and active increase of the original tumour, and local and lymphatic infection of other parts. 14. Carcinoma of the breast accompanied witli severe pain ; enlargement and resolution of lymphatic glands ; operation; recovery ; well three years later. — Ann N., Chap. XV.] Carcinoma. 243 aged 51, the mother of nine children, came under my care on February 10, 1882, with a tumour the size of an orange, in the upper half of her left breast. It had been growing for three years, and for the first two and a half years gave but little trouble ; for six months it had increased rapidly, and was the seat of severe pain. Three months previously the axillary glands enlarged, but they subsided under treatment. On admission the tumour is very hard ; it has a smooth outline, and the skin over it is "puckered." The nipple is retracted. No enlarged lymphatic glands are to be felt. On February 14 the breast and tumour were removed, the axilla was explored without result, and the case did well. The tumour on section presented in its centre all the features of true scirrhus j around its periphery it formed a good example of the more rapidly growing and softer medullary cancer; the tumour exhibited at the same time the microscopical ap- pearances of the slow and rapidly growing varieties of carcinomatous disease. In 1886 this patient was well. 15. Tuberous carcinoma of breast loith infiltrated skin; natural nipple; enlarged axillary glands, folloio- ing a bloiu, associated with albuminuria ; 010 operation. — Maria R., a healthy looking old woman, aged 72, came under my care in April, 1884, with a tumour in her right breast. She was a married woman, and had had eight children, all of whom she had suckled without trouble. She had always enjoyed good health. Five years ago she struck her breast severely against the corner of a washing tub ; swelling and pain followed, and when the immediate effects of the injury had subsided, a lump remained. Six months ago this lump suddenly began to enlarge and become the seat; of pain ; for this she sought advice. Her family history was good. 244 Diseases of the Breast, [Chap. xv. When seen a tumour the size of a tea-cup occupied the u])per and outer segments of the right breast. The skin over it was part of the tumour, and was red from congestion, fixed to the growth, and hard. It was in parts slightly cedematous. The nipple was natural. The axillary glands slightly enlarged. The breast and tumour moved freely over the pectoral muscle. Pulse good. Urine, specific gravity 1012, contained albumen. Under these circumstances no operation was advised. 16. Carcinoma of the breast ivith ttihercidated skin and carcinoraa of spine ; no operation justifiable. — Eliza E.., aged 44, a single woman, came under my care on May 1, 1877, with a tumour about two inches by one and a half in the right breast, which had been gTOAving for about five months. When first discovered it was the seat of an occasional shooting pain. The tumour was hard and nodulated, and clearly formed part of the breast. It moved freely with the breast over the deeper parts. The skin over it was "puckered," and in it were many pea-like tubercular cancerous in- filtrations. The nipple was retracting, and the axillary glands were unaffected. About six weeks before ad- mission she became lame in the right leg, and pain passed from the loins down the leg. This so increased in severity that she was unable to walk, and some- times in her sleep her right leg started. On admission she was unable to sit up without experiencing great pain in her back from the mid- dorsal region to the sacrum, and there was tenderness on pressure over this recrion, and over the right sciatic nerve. She could flex the right thigh partially, but she could not lift the leg from the bed. There was no loss of sensation in the limb. With these symp- toms it was assumed that secondary disease existed in the spine, and no operation was advised. 17. Carcinoma of the hreast; tubercular infiltration Chap. XV.] Carcinoma. 245 of the sJdn ; ulceration of the shin; no operation JKStiJiahle. — Eliza G., a fairly healthy looking woman, aged 53, the mother of two children, came under my care on June 20, 1877, with a hard scirrhous tumour two and a half inches in diameter, in the axillary lobe of her left breast, which had been growing for one year. The skin over the tumour, breast, and sternum, was mottled rerl, as if inflamed, and to the touch was tuberculated, and iri-egularly infiltrated with carcinomatous elements. At one spot the skin was ulcerated from the breaking down of the skin cancer. The breast was fixed to the deeper parts, clearly from the extension inwards of the disease. The axillary glands were likewise infiltrated. The nipple was not retracted. 18. Carcinoma of the breast ofawoman^ aged 25, in tioo separate masses; operation refused. — Mrs. S., aged 25, discovered, in January, 1872, a small lump in the upper half of her right breast, but as it gave no pain she disi-egarded it. She had been married seven years, but had not been pregnant. When seen in February, 1873, one year after the discovery of the tumour, the u|)per half of the right breast was occupied with a nodulated mass the size of an orange, which evi- dently infiltrated the gland with the skin over it, which was puckered. Below the nipple there was a second tumour the size of a walnut, which was uncon- nected with the first. The skin over it was dimpled. The nipple was retracting, and the axillary glands enlarged. Operation was refused. 19. Infiltration of breast folloiving the disappearance of cystic formation ; cupping of skin from scar of abscess irhich existed tv)enty-tivo years before. — Susan K., aged 48, the mother of one child twenty-two years previously, when she had an abscess in her right breast, came to me on November 27, 1865, with great thickening and enlargement of her right breast, associated with pain. 246 Diseases of the Breast. [Chap. xvi. The integument over it on tlie outer side was drawn down to the gland (dimpled). Two years previously this woman had been under my care for two swellings, which were taken to have been cysts, in the same breast, which had disappeared. November 5, 1866, the left breast became indurated like the right, and this rapidly developed whilst the right remained stationary ; nodules ajDpeared also upon the skin. Operation refused. The cupping of the skin was due to the contraction of the scar of the abscess which had existed twenty-two years before, the enlargement of the breast making the depression more marked. CHAPTER XYI. CYSTIC TUMOURS OF THE BREAST. "We now come to w^hat is at once the most interesting, and at the same time the most per^jlexing section of the whole range of diseases of the breast, since it is cystic disease of the gland that, to my mind, makes any pathological arrangement in such a work as this of little utility. It is on this account that I deter- mined in these pages to consider breast diseases purely by the light of clinical experience. As I have already urged, there are those who, at the present day, treat of cystic disease of the breast as one of the nature of sarcoma. I, on the other hand, contend that this groujDing is not right, under the belief that cysts are a part of the pattern or architecture of most tumours of the breast, what- ever be their nature, save and excepting scii'rhus, and even with this disease cysts are found. Thus we clinically meet with simple cysts, cystic Chap. XVI.] CiST/c Disease. 247 adeno-fibromata, myxomata, sarcomata, carcinoraata, and what not, and it is left, as yet, entirely to clinical experience to say what is the natural tendency" of cystic disease. I shall, in the following pages, describe cases of all these varieties of cystic disease, and I shall, I trust, show that the greater proportion by far of all these cases is, so far as I can learn, cured by free removal ; that is to say, that recurrence after such treatment is exceptional. The bearing and importance of this fact are ob- vious, for if it be so, there is much reason for insist- ing upon the restriction of the term sarcoma at the bedside. Under this heading I propose to grouj) all tumours of the mammary glands made up of cysts, wl\ether those cysts are multiple or single, whether they con- tain fluid alone, or are more or less filled with adeno- fibromatous, adeno-sarcomatous, or adeno-carcinoma- tous intracystic growths. I shall not stop to inquire into the different methods by which the cysts are formed, since I believe it to be impossible clhdcally to make out, otherwise than in exceptional cases, whether the cysts are due to an obstruction of a galactophorous main or branch duct (retention cyst) ; or to the exudation of fluid into the intercellular spaces of the connective tissue of the breast (lacunar cysts) ; or to the growth of papules into a duct or acinus from the connective tissue of the breast and their subsequent junction. Neither can the surgeon speak with certainty in all cases as to the absence or presence of an intracystic growth, nor as to the nature of the growth. In a large proportion of cases in which the cyst contains solid growth, a diagnosis of its nature can, however, be made, but the diagnosis is then more determined by signs and symptoms other than those 248 Diseases of the Breast. [Chap. xvi. associated with the presence of a cyst. To these points attention will be drawn later on. I would, however, for the sake of convenience and possibly of clearness, divide the subject up into cer- tain sections, and consider : 1st. The cystic degenerations of the breast as met with in the old, as well as in glands which have long ceased to be active; involution cysts as they are called (Plate YIII. Fig. 5). 2nd. Cystic tumours of the gland, single or mul- tiple, of glandular, duct, or connective tissue formation luWiout intracystic growths (Plate YII. -Fig. 1). And, 3rdly, cystic tumours of the breast of what- ever kind in which papillomatous, adenomatous, sar- comatous, or carcinomatous intracystic gro^vths are present (Plate VII. Figs. 2, 3, and 4). These three classes will be considered in order. Group I. — The cystic degeneration of the gland as met ivith either hi the old or obsolete gland. This condition must, without doubt, be recognised, for it is found in the breasts either of the old, 'or of those in whom the glands have ceased to be active, and are, as it were, undergoing involution changes. Meaning by this term involution change, an irregular form of atrophy, a condition to be expected in any tubular or acinous gland, and, as a fact, one well known in the kidney, the thyroid, and occasionally in the pancreas. It may be that a single lobe or lobule is under- going this special form of degeneration, but more probably the change will have affected the whole gland, which, on dissection, will be found to be made up of innumerable small cysts, varying from the size of a hemp-seed (the more common size) to that of a pea, whilst in exceptional cases these dimensions, in isolated cysts, may be considerably exceeded. PLATE VJI. Kig. 2. Fis:. 1. Fig. 3. CYSTIC DISEASE. }• Cystic Disease with discharging Nipple. 2. Cystic Sarcoma. ». Wstic Sarcoma bursting tliruugh Coverings. 4. Cystic Carcinoma, Chap. XVI.] Cystic Disease. 2.19 The cysts appear more as a series of dilatations of the lactiferous ducts (varicose ducts) than of the gland •structure, although in certain cases both ducts and gland structure are involved. On dissecting these cases and on separating the ducts, or rather unravelling them, the gland as a whole may be involved, and in a dissection I made many years ago, the breast appeared, when suspended by the nipple, to be made up of strings of small cysts connected together by the main and branch ducts. Some of the cysts had direct tubular communication with the neighbouring cysts, as proved by the passage of bristles through the ducts from one cyst to another, or by the fact that many of the cysts and ducts could be inflated by means of a fine tube introduced into one or other of the nipple ducts. In many cases, however, this direct communication cannot be made out. These cysts, when unopened, have usually a greenish or black appearance, and when opened they are found to contain a blackish viscid or mucoid fluid, more or less coagulable by heat, and mixed at times with fat and epithelial elements, such being the pro- ducts of degenerating epithelium. The breast, thus aflected, feels on manipulation in thin subjects as a coarse gland, with here and there a pea-like tumour, whilst in fat women the change often cannot be clinically recognised. This change is rarely associated with pain, or with a greater amount than can be described as uneasiness. There is seldom any discharge from the ni])ple in these cases, although there may be at times. Why there shouhl not be a discharge always can only be explained by the fact that the ducts become obstructed, and probably by their epithelial elements. In exceptional cases some enlargement takes place of a single cyst or group of cysts, and under such 250 Diseases of the Breast. [Chap.xvi. circumstances a cystic tumour is formed, for which surgical advice is sought. I have seen many of these cases. In some the cyst Avas single, and relief was given by simply drawing oflf the fluid by means of a small trocar and cannula ; in other cases two or more cysts existed ; in a few they were still more numerous and showed signs of activity, so that excision of the aflected lobule or whole gland was required. In not a few cases the cysts have become the seat of intracystic, sarcomatous, adenomatous, or cancer- ous gTOwths, for which extirpation of the whole gland has been necessary. To these attention wiU'be drawn later on. What I would wish now to be recognised is the fact that there is in the mammary glands which have long ceased to be active, and in those of women past child-bearing, a cystic degeneration of their ducts and glandular structure which may simply remain as such or take on active changes. Under the latter circum- stance, a cyst or many cysts may either enlarge so as mechanically to cause trouble or become the seat of intracystic, adenomatous, sarcomatous, or carcinoma- tous gi'owth which will run the usual course of such tumours. In the two following cases this cystic involution change is well illustrated. In the tirst the whole breast was excised, and a good result ensued. In the second some of the cysts were relieved by tapping, when the remainder disappeared. This favourable result is one that not infrequently follows an expectant treatment, but it is not in the majority of cases to be expected. The hope of obtaining such a success by leaving things alone, should not induce the surgeon to withhold his hand in any case in which the breast is clearly enlarging, althousfh it mav be sufficient to sanction a watching line of treatment where the progress of the trouble is slow. Chap. XVI.] Cystic Disease. 251 Case 1. Involution cysts of hr east which had long ceased to he active, simulating cancer ; excision of gland ; recovery. — Mrs. T., aged 52, the mother of many children, all of which she suckled, consulted me in May, 1885, for some affection of her riglit breast, which had been slowly coming on for about six months. It began as an enlargement of the axillary lobe, and later on as a swelling of the whole breast. At times there was a discharge of a clear fluid from the nipple and some slight pain. When seen the whole breast was coarsely enlarged and indurated ; one lobe, the axillary, seemed to be generally infiltrated with some new material ; the other lobes were full of nodules which appeared to be cystic. The nipple was natural, but pressure upon the breast caused from it a slight discharge of a serous fluid. The skin over the breast was healthy, as were the lymphatic glands, I regarded the case as one of carcinoma, with cystic degeneration of the gland, and advised excision. On May 13th the operation was performed, and a good recovery rapidly followed. This lady is still well. Description of breast by Mr. Symonds. — Just be- neath the nipple was a cyst, one inch in diameter, with a thick dark wall, embedded in condensed breast tissue, containing many smaller cysts. Everywhere through the breast these cysts existed, and all were filled with a creamy grey fluid, which exuded as so many beads when the breast was squeezed. The galactophorous ducts were filled with this same mate- rial, which exuded from the nipple on compression. The whole organ had a uniformly whitish-grey colour, but nowhere was any solid growth visible. The out- line of the breast seemed also normal, and there was no infiltration of, or alteration in, the surrounding fat. 252 Diseases of the Breast. [Chap. xvi. 2Iicroscopical examinafioR. — The flaid was not examined fresh, but from its resemblance to that seen in similar cases, and from its appearance in the hardened sections, it, no doubt, was composed of de- generated cells and fatty granules. The appearances seen in the sections might be < /' '" f Fig. 7.— Breast undergoing Cystic Degeneration. Case 1. shortly described as showing the ordinary breast tissue containing many cysts (Fig. 7). There "are groups of small tubes cut in various directions, some having a dis- tinct lumen, many showing only a number of irregular cells. These groups are always surrounded by fibrous tissue containing fat vesicles, and represent the ordi- nary breast lobules. The adipose tissue is in some places tolerably abundant. Many of these tubes are much enlarged, having a wide lumen, occupied in Chap, xvi.j Cystic Disease. 253 many instances by p:ranular matter, and lined with two or more rows of cells. As the accumulation of secretion increases, the central aperture enlarges until a small cyst is formed visible to the naked eye. These changes are all obvious in the woodcut below, and occur in all parts of the breast. Besides these cysts with a round lumen, there are many apertures with a sinuous outline, and many with villi or buds projecting towards the cavity. These are all lined wdth two or more rows of cells, the inner row being more or less columnar, and taking the stain (logwood) more deeply than the outer or irregular cells. The buds or projections are covered by the .same cells, and have vessels and fibrous tissue as a basis. The appearances are shown in the illus- tration. Again, the largest cysts have a wall composed of lamellae of fibrous tissue, are lined by large columnar cells, and contain some of the graimlar material above described. The cells form a definite layer much altered from the regular columnar shape by mutual compression \ usually the layer is two cells thick, but there is no regularity in the arrangement. The fibrous tissue seems no more in amount than that proper to the breast, the cyst formation appearing to be th.e only morbid change. From the description given above, and from the appearances presented in the drawing, these cysts all seem to form out of the mam- mary acini and ducts. Case 2. Cystic dp-generatlon of hreast which had never ficcreted milk. — Mrs. S., aged 34, the mother of one child 17 years of age, consulted me in February, 1880, for some disease of her right breast. She had suckled with her left breast, but not with her right, as that gland had never secreted milk, although it in all other ways appeared to be natural. Three months before I saw her she accidentally 254 Diseases of the Breast. [Chap. xvi. discovered a lump in the right breast, wliich had steadily increased. It was not the seat of pain, but only of uneasiness. When I saw her there were four or five nodules the size of nuts in the gland, and these, from their globular outline, I took to be cysts. The whole gland felt coarse to the hand, and knotty. I punctured one of the nodules for diagnostic pur- poses, and let out some serum. The others I left. Six months later, when last seen, there was no change in the breast. The cysts were doubtless due to cystic degenera- tion of the gland from involution changes. Group II. — Cystic twmours of the gland ; single or multijjle ; of glandular, duct, or connective tissue formation without intracystic growths. That these cystic tumours of the mammary glands are not uncommon in practice must be fully recognised, aJthough it must be acknowledged that they are too often not diagnosed until by some error tliey have been subjected to surgical operative treatment. I take it few surgeons have been so fortunate as not to have removed a breast for a supposed cancer which turned out to be a cyst ; and fewer still who have not, as spectators of such a case, been well sprinkled with the fluid of a tense cyst accidentally opened by the hand of a surgeon in his attempt to cut into or excise what he regarded as a solid tumour. Formation of cyst§. — These cysts are doubt- less' developed in several ways. Some are unques- tionably ^^ duct cysts" that is, they are formed first by an obstructed and subsequently by a dilated irri- tated duct, the duct being more commonly a branch than a main duct, and occasionally a duct leading directly into an acinus of the gland. When the branch is a large one the cyst is likely to be single ; Chap. XVI.] CVSTIC D IS EASE. 25^, when it is placed nearer the gland structure the cysts are more likely to be numerous. The cystic tumour in the former case appears as a globular, tense, more or less deeply placed growth ; and in the latter as an unequal enlargement of one of the lobules of the gland, with a more or less bossy outline and semi- Huctuating feel ; this latter symptom turning much upon the size the cysts attain and the depth of gland structure which covers them in. The fluid contained by these cysts varies much. In the majority of cases it is clear and serous, in others it will be brown or slightly blood-stained, in a few cases it will be viscid and mucoid. When it is deeply blood - stained or sanguineous the surgeon should suspect that it is not a simple but a proliferat- ing cyst in which some intracystic growth exists. In almost all cases the fluid will be albuminous ; at any rate, I have not yet met with an example in which it was otherwise. At times fluid may escape naturally or may be pressed from the nipple, and when this takes place the diagnosis of a duct or glandular cyst may with confidence be made. In half the cases of this affection no such symptom will, however, be found, but this fact need not diminish the value of the symptom for diagnostic purposes when it is present. Others of the cysts have a " connective tissue origin.^' That is, they originate outside the ducts of the gland, or the gland structure, and are formed by the effusion of fluid into the connective tissue which binds the lobes and lobules of the gland together. Such cases are usually single, but may be multiple. They are commonly of slow formation, and as a result have thick walls. They are always smooth on their inner surface, and as a rule contain serous fluid. At times the fluid is, however, mucoid or dark. When the cyst appears in the breast of a thin woman its 256 Diseases of the Breast. [Chap. xvi. tense globular outline, unassociated with any of the symptoms which are recognised as characterising the existence of a cancerous or other tumour, should sug- gest its nature as well as its treatment, for the puncture of the swelling with a fine aspirating needle will prove much. When the cyst shows itself in the breast of a fat subject the diagnosis must be difficult, but its true nature should ever be suspected, even when all other symptoms of more solid growths have by the lapse of time failed to manifest themselves. The more breast tissue there is to surround a cyst or cystic tumour, the greater the difficulty of diagnosis. The longer the tumour has existed without the manifestation of the well-recognised symptoms of cancer or other growth, the sti'onger the probability of its being cystic. In all doubtful cases, however, the fine exploring needle of an aspirating syringe will avail much for diagnostic purposes. In but few of these cases can the surgeon without exploration diagnose between the simple cyst and the cyst with proliferating intracystic growth. Simple cysts of the breast exist, without in many cases ever developing into anything else, or becoming the seat of solid grow^th. With the majority of cystic tumours this, however, is not the case, for what may seem to b3 the most simple or innocuous cyst may be expected, if not cured, to become the seat of some proliferating intracystic gTowth, which will be adenomatous, sar- comatous, or carcinomatous, according to the tendency of the tissue to form, and of the individual to develojD, either special variety. The mere presence of a cyst in the mammary gland must be accepted as evidence of some unnatural local irritation, inflammatory or otherwise, whether that irritation has originated in, or become localised about a gland duct, lobule of gland, or connective tissue. If the irritation is subdued or subsides, a cure, or at Chap. XVI.] Cystic Disease. 257 any rate freedom from fresh developments of the local trouble may be looked for; but should the local irrita- tion continue or intensify, fresh developments must be expected, and such of necessity will assume the form of a new growth either of the glandular, epithelial, or con- nective tissue type, and lead on to the formation of an adenomatous, epitheliomatous, or sarcomatous cystic growth, to which attention will now be drawn. In rare cases the cyst will suppurate and undergo a spon- taneous cure. I propose to illustrate the clinical history of this group of cystic disease by means of cases, each case telling its own tale. Case 3. Duct cyst in breast with retracted nipple ; albuviinous fluid draivn off"; cured. (Reported by Mr. H, Caddy.) — Susannah B., a healthy looking, well-nourished woman, aged 24, was admitted into Lydia ward, under Mr. Bryant's care, on the 9th September, 1872, with a large hard, substance in the centre of her left breast. The nipple had quite disappeared, from retraction, but the swelling seemed to point at the surface abotit an iiich above where the nipple ought to be. There was no glandular enlarge- ment in the axilla or above the clavicle. The patient's family history had been good, and she herself had been healthy up to thirteen years old, when her back began to grow out both backwards and to the right side. She had no remembrance of any injury, and a year later she was employed in turning the mangle. About four years ago her tonsils were cut, and two years later she felt slight pain in the upper part of her left breast, which became more severe when she raised her arm. One month before ad- mission she noticed a lump about the size of a filbert, which was movable ; a fortnight later there was a discharge from the nipple. She then sought advice from a medical man, who told her to bathe E— 25 —7 258 Diseases of the Breast. [Chap. xvi. it with warm water ; this benefited her at first, but the lump grew, and the discharge from the nipple increased and became mixed with blood. She then came into the hospital. On admission. A verj tense globular swelling, the size of an orange, was present in the centre of the breast. The nipple was flattened out and some- what retracted ; it discharged a yellow glairy fluid, which could be increased on pressing the tumour. The diagnosis of cystic disease of the breast was made. September 12th. A small cannula was introduced into the cyst, and about four ounces of a pale yellow fluid were drawn ofl". A drainage tube was introduced into the cyst. 16th. The breast discharged a Kttle for a few days, but it ceased on the 19th, and on the 21st she left the hospital well. Two years later the patient rej)orted herself as still well. Case 4. Cyst in breast, lohich disappeared after taj^nng. — Eliza T., aged 43, a married, childless woman, came to me February 12th, 1886, with coarse, indu- rated breasts, and a tense, globular tumour, the size of a walnut, in the left gland, which seemed to be a cyst; there was no discharge from the nipple. For diagnostic purposes this cyst was punctured, and clear serous albuminous fluid dra^vn off. By April 16th the swelling had gone. Six months later no return had taken place. Case 5. Duct cyst in breast, lohich spontaneously suppurcLted ; was opened and cured.— ^liza. H., aged 40, a married, childless woman, came under my care in April, 1870, with a tumour in her right breast, which had been coming for , five years and was increasing slowly. She had had serous discharge from the ni]3ple for two years. The axillary glands were not enlarged. At present there is a free discharge of a Chap, xvi.l Cystic Disease. 259 clear fluid from the nipple, wliich runs wifcliont, but can be increased by pressure. At times the ^_ fluid is blood-stained. There is a tumour the size of an orange at the lower part of the gland. An incision was made into the cyst at its lower part, and some ounces of pus were evacuated. A good re- covery followed. It is probable that the spontaneous suppuration of a simple duct cyst of the mamma is rare. I have not seen any ocher example than the one recorded, in which it was clear that this took j^lace. Tn .Prep. 4753 of the College of Surgeons there is, however, a cyst of this kind, in which at one spot the inner surface of the cyst appears thinly covered with lymph, demonstrative of an inflamma- tory action. In this case, as in the one recorded in this paper, the nipple was retracted from traction on its ducts. The following interesting case has been recorded by Mr. Birkett (Guy's Hosp. Reports, 1872-3), and illustrates the same point. Case 6. Duct cyst of the breast, folloiving a contusion; retracted nipjjle ; twelve years later spon- taneous sujypuration and recovery. — A delicate single lady, aged 40, consulted Mr. Birkett for a bloody dis- charge from the nipple, which she had observed for w . nine or ten years. She attributed it to a blow. The '-^"^^ nij)ple was retracted. When seen a small, fluctuat- ^-^^ *'^ ing, painless swelling was present near the nipple, ■• with induration of the inland tissue around it. By > compressmg the tumour, serum escaped from the (^iri^ nipple. Four years later, when but little change had u^^-^X?!;, taken place in the tumour, the discharge from the ^Zjlc^ nipple ceased and the tumour inflamed. Suppura- tion soon followed, and the abscess burst, ^vhen more than ten ounces of pus escaped, and a piece of solid . ,^ substance as long as the little flnger escaped. This 2 6o Diseases of the Breast. [Chap. xvr. was the statement of the patient. The discharge, which contin.ued several days, diminished ; the hole, which looked very deep at first, contracted and filled up, and at last became healthy. In fact, adds Mr. Birkett, the disease was cured by the efi'orts of nature alone, and has never reappeared in the eighteen years which have since elapsed. Case 7. Cystic tumour of hreast; cured hy an iricision into its cavity, and drainage. (Reported by Mr. Duckworth.) — Louisa N., a healthy looking married woman, aged 45, was admitted into Lydia ward, Guy's Hospital, on May 1st, 1879, under Mr. Bryant's care. Her paternal grandmother had cancer of the breast. About three months ago she felt some pain in the region of the left breast, but noticed no lump for a month, when she felt one about the size of a walnut on the outer side of the gland. It was freely movable, and when she slept on her right side would slip towards the inner side. It was occasion- ally the seat of a gnawing or shooting pain. She has had one stillborn child, and never suckled. On admission. There is a hard, irregular, ovoid, lobulated swelling about the size of an egg, on the outer side of the left breast. It is very freely movable, and the skin over it is not infiltrated. The tumour seems, however, to be slightly attached by one end towards the nipple, which is normal. Operation. — May 6th, under chloroform, an ex- ploratory incision was made about two inches in length on. the outer side of the breast into the tumour, which was found to be a cyst. When opened about an ounce of clear fluid escaped. The cavity, which was smooth, was washed with iodine and water, after which a drainage tube was put in and the wound dressed with lint soaked in terebene oil. 8th. No discharge, wound health}'-, drainage tube removed. Temp. 97 "S^. ciiap. XVI.] Cystic Disease. 26 r 12th. Tinct, ferri percli. Vi\x, tinct. calumb. ii\^xx, aq. 3J, t. d. s. Temp, normal. 20th. The wound has nearly healed. 24th. Discharged cured. Some months later this patient was well. Case 8. Cyst in breast, simulating carcinoma ; exploratory incision; 2^^^'>^0fJ^'>'^y ^f ^V^^; recovery. — Martha J., aged 50, a married woman, came under my cave on January 9th, 1886, with a tumour the size of an orange, occupying the centre and axillary half of the left breast, retracted nipple, and healthy skin over the tumour. No axillary glands found enlarged. She first noticed the lump five years previously, which liad steadily and almost painlessly increased. It was the seat of an occasional shooting pain. The tumour and breast were one ; it was hard and inelastic ; no nipple discharge. An exploratory puncture or incision was determined upon. On January 19th, when the woman was under the influence of an anaesthetic, fluc- tuation was detected ; an incision was then made into the tumour in a line radiating from the nipple, and a cyst opened ; three ounces of a dark-coloured fluid, containing cholesterine, was evacuated. No intra- cystic growth was found, and the lining membrane of the cyst was smooth. The cavity exposed was then plugged with iodoform gauze dipped in terebene oil to excite suppuration, and the case did well. Case 9. Cyst in breast treated by incision; douhffid thickening reinaining ; well. (Reported by Mr. Duckworth.) — Harriet S., a single woman, aged 35, was admitted into Lydia ward on May 21st, 1879, under Mr. Bryant's care. Six years ago she had an abscess in her neck. About four months ago the patient experienced, when at work, a dragging pain in her chest and shoulder, and found upon examina- tion a small hard lump, about twice the size of a pea, in her right breast. It was freely movable, and 262 Diseases of the Breast. [Chap. xvi. occasionally gave pain at the back of her shoulder. She has no recollection of having received an injury. On admission. To the left of the nipple of the right breast there is a hard, irregular, lobulated lump the size of a small orange, with a base occupying about the area of a half-crown. It is freely movable, and does not infiltrate the nipple or breast. The axillary glands are slightly enlarged. May 21st. She is menstruating ; her menses have been irregular for some time. They generally last ten days. 27th. Under chloroform, an incision was made over the tumour, radiating from the nipple, and about two and a half inches in length. Having cut into the tumour, about an ounce of brownish fluid escaped ; the walls of the cyst were smooth. The parts were washed out with iodine and water, and a drainage tube introduced ; the edges were then partially brought together with four sutures. 28th. Temp. 98°, pulse 88. 29th. Temp. 98-2°. Two sutures taken out; wound looks healthy. June 1st. Temp. 98-9°, pulse 96. Wound closed well, narrow line of granulations on surface. A lump about size of a hazel nut felt below the incision. 24th. Patient left the hospital cured. Case 10. Cyst in right hreast ; treated hy a free incision; no intracystic disease; jyatient ivellfour years later. (Reported by Mr. Gowan.) — Mary S. R., aged 40, was admitted on October 15th, 1883, into Lydia ward under Mr. Bryant's care. Patient is a tall, well-formed, and well-nourished woman. She is a widow. Has never borne a child, and has never been injured in the breast. Two months ago she first noticed a lump in her right breast about the size of a pigeon's egg, a little to the right of the nipple. It has gro^vn somewhat rapidly since. Chap, xvr.] Cvsric Disease. 263 On admission. The riglit breast does not appear miicli larger than the left. Both are well developed and firm. The right nipple is slightly tinged with Lrown, but not retracted, nor is the skin dimpled. A •tumour, about the size of a large orange, occupies the upper and outer quadrant of the right breast ; it is globular and smooth, and indistinctly fluctuates. Neither the skin nor adjacent muscles are implicated apparently. October 16th. Under chloroform the tumour was punctured with a scal})el, when about one and a half ounces of blood-stained serum gushed out. The inci- sion was enlarged, and the cyst walls were found to be free from growth, smooth and thin. The wound was plugged with iodoform gauze, and dressed with gauze and flannel bandages ; the arm was fastened to the side. November 19th. Left hospital; there is still an open granulating wound 1| inches long by ^ inch. Patient's general health is good. Three years later this patient was quite well. Case 1 1 . Deeply placed cyst in sternal lobe of righ t breast, simulating adenoma in gland ; exploratory in- cision ; plug. (Reported by Mr. C. Lloyd Jones.) — Margaret V., a domestic servant, aged 37, was admitted into Lydia ward on February 23rd, 1877, under Mr. Bryant's care. She stated that her father died at seventy years of age of some internal tumour, and her mother at thirty of hepatic disease. Her brother and sisters were all healthy. She was unmarried, and always enjoyed good health. She fancied that she had become a little thinner during the past winter, and lately her menstrual intervals had become three weeks instead of a month. Three weeks before ad- mission she happened to place her hand on her right Ijreast, when she noticed a lump there. She felt no 264 Diseases of the Breast. [Chap. xvi. pain in it, and it had not increased in size since it was first noticed. When admitted, the hand pressed flat against the breast at once detected, at the ujDper part of the right breast, a tumour which was nearly circular in shape, about two and a half inches in diameter, and flattened. It felt hard, and its surface was distinctly lobulated. The tumour was movable with the breast, the skin was nowhere puckered nor adherent, and there was no pain on manipulation. The nipple was normal. No enlarged glands in axilla or elsewhere. The patient could assign no cause for the appear- ance of the tumour, and she stated that she was, as she appeared to be, in very good health. March 9th. Under an anaesthetic an incision was made into the tumour, when blood-stained serum escaped ; the lining membrane of the cyst which occu- pied the posterior part of the lobe was smooth ; the cyst was plugged. 15th. Wound nearly well. The patient had not had one bad symptom or any rise of temperature. Remarks. — In this case the true diagnosis was not at first made, nor was the true nature of the case suspected ; the tumour had none of the appearances of a cystic growth, since it was quite inelastic, and its surface was nodular and hard. The cause of this error in diagnosis is to be ex- plained by the position of the cyst, which was covered in by gland of quite three-quarters of an inch in thick- ness, the gland giving the nodular outline and yielding the firm feel. At one time the question of infiltrating carcinoma was considered^ on account of the growth so closely involving the gland and appearing as an infiltration, but this was dismissed in favour of the adenoid view, the outline of the tumour appearing more of the latter disease. Chap. XVI. ] Cystic Disease. 265 Had this case been punctured for diagnostic pur- poses its true nature would have been discovered. Case 12. Cyst of mamma mistaken for carcinoma^ and excised ; cure. (Keported by Mr. C E, Perry.) ■ — Anne F., a married woman, without children, aged 47, was admitted into Lydia ward, under Mr. Bryant's care, on January 18th, 1875, with a hard round swelling, about the size of a small tennis ball, in the upper and outer part of her left breast ; it was movable with the breast and without pain except on pressure. It was regarded as a carcinoma. It ap- peared that an aunt on her mother's side had died of cancer in the breast. She herself had had good health until about five months before admission, when she felt a swelling about the size of a small Qgg in her left breast ; it remained about the same, without pain, for three months, when, pain coming on, she sought advice, and had some embrocation, which she left off after a few days, as it brought out a rash. She then fomented it, and nothing else was done up to the date of her admission. January 26th. Chloroform having been given, the breast and tumour were removed by two elliptical incisions. On cutting into the tumour it was found to be a simple cyst full of fluid. The patient did well after the operation, and left the hospital convalescent. The preparation is in the Guy's museum, ISTo. 2290^*^. Case 1 3. Sero-cystic disease of right breast ; re- moval of lobe ; inflammation of the remainder, and recovery. — Mrs. S., a childless, married woman, aged 50, was brought to me by Dr. Wallace, of Hackney, March 15th, 1875, with a tumour in the axillary lobe of her right breast, which had been steadily increasing for three months. The tumour was hard and lobulated, and I supposed the growth to be simi)le, and advised its excision. 2 66 Diseases of the Breast. [Chap. xvi. Marcli 21st. On excising tlie tumour I found it to be made up of cysts, and in making the section of the gland the whole breast was found to be full of small cysts (invokition cysts), many of which I punc- tured. I could not remove the whole gland, as I had undertaken to remove the tumour alone. During convalescence the remainder of the gland inflamed and indurated, putting on the clinical features of acute cancer. The induration, however, subsequently entirely subsided, and the patient re- covered. In 1881 she was quite well. The tumour on removal v/as made up of cysts of various sizes, the largest being about the size of a walnut. The cysts contained fluid of different kinds. In some it was clear, in others blood-stained, whilst in a few it was mucoid and greenish. There were no intracystic growths. Some of the ducts were, open, and through these bristles could be passed. . The gland was clearly undergoing cystic degenera- tive chano-es, and in the lobe removed these chan£;3s had gone on rapidly. Case 14. Sero-cystic disease of breast folloiving injury ; excision of gland ; iKitient well six years later. — Miss D., aged 34, patient of Dr. S. Tayleur Gwynne, of Whitchurch, Salop. In June, 1864, she had a blow upon her left breast, which was followed by pain for two months, and then the appearance of a swelling. In January, 1865, when I saw her, the swelling clearly occupied the sternal half of the gland, and was tense, giving the idea of a cyst. General health good. By December of the same year the tumour had increased, and had become lobulated ; it, moreover, was more painful. Is'ipple and lymphatic glands normal. December 29th. Breast removed and found to be ciiap. xvi.j Cystic Disease. 267 a pure cystic disease of the gland. Cj^sts contained brown thin fluid, some clear serum. No intracystic growths. Eapid recovery ensued, and six years later the patient was well. Case 15. Sero-cystic disease of breast ; excision of breast; jmtient well six yea7's subsequently. — Mrs. R., aged 40, the mother of seven children, was brought to me by Dr. Wilton, of Sutton. Her left breast has no nii)ple ; it had been destroyed by old ulceration. The right breast is the seat of cystic disease, which involved the whole gland, and had been going on for months. The gland was very large, with an irregular outline, and clearly contained cysts of all sizes. The nipple and skin over the breast were normal. January 29th, 1881. Breast removed, and the operation was followed by a good recovery. The gland was full of cysts of all sizes, Avhich contained a great variety of fluids. No intracystic growths could be found. January, 1882. Pregnant. Natural delivery. Left breast strapped. No nursing trouble. 1887. This patient is now well. Case 1 6. Sero-cystic disease of breast ; excision of breast ; jyatient well eleven years later. — Mrs. S., aged 39, the mother of three children, all of which she had nursed without trouble, the youngest being fifteen years of age, was brought to me by Mr. Joseph Burton, of Blackhcath, in 1876, with an irregular nodular tumour in her left breast, wdiich had been coming on several months. It was ap2:>arently cystic, and involved the whole gland. The skin over the gland was normal. Her mother had had cancer of her breast, and the sister some internal tumour, February 16th, 1876. Breast removed. On sec- tion a large cyst without intracystic growth, contain- ing fluid as dark as ink, was found, with many smaller ^> 268 Diseases of the Breast. [Chap, xvi, cysts containing fluid of different characters. In fact, the whole breast was full of cysts of different sizes. A good recovery ensued; and in 1887, eleven years later, the patient was well. Group III. — Cystic tumours of the breast of whatever kind in v^hich papillomatous, adenomatous, sar- comatous, or carcinomatous intracystic growths are present. If, clinically, simple cystic tumours of the breast are fairly common, pathologically they must be pro- nounced to be comparatively rare, for it is, I think, indisputable that in the majority of cystic tumours of \ the breast, of whatever character, of duct cysts, gland cysts, or connective tissue cysts, some solid element can usually be found proliferating from their lining walls, either in the shape of a small sessile or pedun- culated outgrowth, or of a solid tumour composed of glandular, epithelial, or connective tissue elements; the nature of the growth being determined by the seat and persistency of the local source of irritation which originated the formation of the cyst. When the cyst is single the growth %vill of necessity involve it alone. When multiple, some of the cysts may be simple or non-prolifei-ating, while others are proliferat- ing, the association of the two kinds in the same gland being not uncommon. The surgeon consequently meets with cystic tumours of the breast, in which in one case paiyillomatous growths are present ; the papil- loma being a simple outgrowth of the cyst wall, in the same way as the same growth may spring from the nipple or other structure ; whilst in another case the cyst may have an adenoid growth hanging or springing from its walls, the growth appearing either as a pedunculated intracystic growth washed with the cyst contents, or the cyst may be filled with sarco- matous 01- adenoid tissue either of a loose or more cii.ip. xvi.j Cystic Disease. 269 solid structure ; the tumour in the latter case, when the cyst is full, losing much of its cystic character and ap])roaching the more solid kind, whilst the intermediate conditions between these two extremes suggest and give su])port to the view which some pathologists entertain, that these solid adeno-sarcomatous or tibro- matoiis tumours as a rTiIe originate in cysts, and only ditl'er in the degree in which the cyst cavity is tilled. In many cases, doubtless, what appears to be an intra cystic growth is nothing more than a growth originating in the connective or glandular structure outside the cyst, but projecting into it, and having its surface bathed with fluid, the fluid being either the secretion of the cyst wall or an exudation from the growth itself into the cyst cavity. The same re- marks are also applicable to sarcomatous and carcino- matous tumours. Without doubt a large number of tumours of the breast begin as cystic, and pass on to become sarcomatous and carcinomatous ; the con- nective tissue element in the former case, and the epithelial element in the latter, so increasing and filling what was at one time simply a cyst or cysts, as clinically to form what is now known as a cystic sarcomatous, cystic adenomatous, or cystic carcinoma- tous tumour. These varieties in the cystic disease maintain the same clinical features as characterise the more solid kinds ; the symptoms of the solid and the cystic being the same in each, with the addition in the latter of the cyst element. The diagnosis of a cystic adenoma, cystic adeno-fibroma, sarcoma, or car- cinoma is consequently to be determined by the same points as are known to characterise a solid adeno- fibroma, adenoma, adeno-sarcoma, or carcinoma, with the addition of such clinical symptoms as are clearly referable to the existence of cysts. The following cases will best illustrate the clinical features of the disease. 270 Diseases of the Breast. [Chap. xvi. Case 17. Cystic {clAict) adenoma of breast ; exci- sion of lobe. — Mrs. D., aged 45, the mother of four children, the youngest of whom was eight, and who had only nursed her first child, consulted me in April, 1876, for a tumour in her right breast, which had been discovered six weeks, and had steadily increased. I took it to be a cyst. The swelling was central and very cystic to the feeL The nipple projected more on the right than the left side, and discharged blood- — > stained serum. The skin over the gland was healthy and the lymph glands were natural. I advised punc- v/ ture or incision, and excision if the cyst was found to contain growth. The late Mr. Jardine Murray, of Brighton, operated in May, 1876, and found a pedun- culated intracystic growth, which, on examination, I proved to be an adenoma. He then excised the affected lobe, and a good result followed. rive years later this lady was well. Case 18. Case of cystic adeno-fibronict of the breast, in avjoma.n, aged 71 ; excision of gland ; cure. — Catherine K., aged 71, a healthy looking woman, the mother of three children, was admitted into Guy's Hospital, under the care of Mr. Bryant, on August 7th, 1865. She had always enjoyed good health, and had been able to suckle her children. About last Christmas, some time before admission, she acciden- tally discovered a lump, the size of an egg, in the outer side of her right breast ; it was painless, and grew very slowly for three months, when it suddenly began to increase rapidly in size, and to cause pain. She applied to jMr. Bryant for relief, and remained under his care till she was admitted. On her admission the right breast presented a large tumour, the size of a cocoanut, closely connected with, if not in, the breast. It was irregular in its outline, and evidently in parts made up of cysts, for, in its projecting portions, distinct fluctuation was clearly felt. There was, Chap. XVI.] Cystic Disease. 271 however, much solid matter. The tumour was quite movable, and the skin over it was only stretched ; the axillary glands were also healthy ; the nipple was natural. Kothing but excision promising to be of any use, the operation was performed on August 30th, and a rapid recovery took place, the old woman leaving the hospital in one month perfectly well. On examining the tumour it was found to be made up of a firm solid material, which contained several large cysts. These cysts held a blood-.stained glairy fluid, and in parts the solid growth seemed to threaten to degenerate and break up. The tumour measured seven inches by six ; it was very firm in its consistence, and to the eye appeared of a sarcomatous nature ; it was tough, and was witli difficulty broken down ; in parts, however, it had more the aspect of the looser kind of adenoid tumours. By the microscope, the opinion formed by the naked eye examination was confirmed, for the structure generally was an admirable specimen of the more fibrous kind of adenoid tumour ; tubes were here and there visible, and also well-developed cell structures, as a drawing by Dr. Moxon indicates."^ As an example of an adeno-tibroma in an old woman, the case must Vje regarded with great interest. Case 19. Cystic, sarcomatous disease of the breast of fifty years^ growth in a woman seventy-three years of age. — E. C, a healthy looking old woman, 73 years of age, came under my care on October 5, 1862, with an enormous tumour, the circumference of a soup plate, in her left breast. She was a married woman, the mother of one child, who was fifty years old. During her pregnancy with that child, she observed a small lump in her left breast, which was movable. This * ^\e Path. Trans., vol. xvii. i-. 283. 272 Diseases of the Breast. [Chap. xvi. gradually increased in size, but in such a painless way, that she kept her trouble to herself; about three months before she came to me the tumour burst and discharged much blood-stained serous fluid \ it was on this account alone that she sought advice. When I saw her a large bossy tumour occupied the position of the left breast ; it was fluctuating in parts, and the skin over it was healthy, though mu.ch thinned. The nipple Avas flattened out over it. At one part the skin had ruptured, and the rent appeared as a fissure, with a thin but healthy margin, and through this opening sprouted a large fun- gating growth. The absorbent glands were natural, and the pa- tient's health was good. No opera- tion was sanctioned. Case 20. Cystic {duct) adenoma of hr east, excisiooi of gland. Patient ivell six years later. — Mrs. T., aged 54, the mother of several children, all of whom she had nursed without trouble, consulted me in October, 1880, for a tumour of her breast which she had noticed for about a year. The appearance of the tumour had been preceded for months by the discharge of a serous fluid from the nipple. The tumour was about the size of a tennis ball, hard and globular; pressure upon it caused blood-stained serum to flow from the nipple. The skin over the swelling was natural, and the nipple was not changed. The diag- nosis of a duct cyst was made, and an incision advised into the tumour with the view to an excision should an intracystic growth be found. This was performed on October 23rd, 1880, and the breast removed, as a pedunculated intracystic growth was found in Fig. 8. Pendulous Intracystic Adenoid Growth. Case 20. Chnp. XVI.] * Cystic Disease. 273 the cyst (Fig. 8). A good recovery ensued, and tlie patient was well six years later. The growth was examined by Mr. Symonds, who reports : The growth was one and a quarter inclies in diameter, and was attached by a small ])edicle to the I p|Mp<;j; ;^ ^i"" feN ^ll' * % Fig. 9.— Microscopical Appearance of Breast Adenoma. Case 20. smooth Avail of the cyst in which it was enveloped. It had a deep purple-red colour, was soft, and sepa- rated easily from its attachment. Eound the cyst and in its wall were many dilated ducts, some of large size, but no direct communication could be traced. The cyst appeared to be produced by dilatation of a duct. Nowhere in the breast Avas there any other growth. The tumour had a lobuhated appearance, as ex- hibited in Fig. 8, and its pedicle Avas small ; microscopically the growth showed all the characters s— 25 274 Diseases of the Breast. [Chap. xvi. of a pure adenoma as seen in drawing (Fig. 9). It is composed of large spaces of A^arious shapes, lined by closely set cells. These have large nuclei and one or more nucleoli. The supporting framework is a very delicate fibrous tissue, containing cells of various shapes, besides blood-vessels. From the walls of many acini conical projections grow, which often blend with the op])osite wall. The tumour therefore appears to be a pure ade- noma growing from the wall of a duct. The small amount of fibrous tissue, and the normal characters of the breast tissue immediately round the cyst, negative the view that it is a fibroma budding into a dilated duct. This growth is identical with that called now a ''duct papilloma." Case 21. Cystic duct tumour with 2Jedunculated adenoc' le of breast ; excision ; 2^(^ti&nt well three years later. (Reported by Mr. W. T. Crew.) — Susannah W., a single woman, aged 43, was admitted under Mr. Bryant's care, into Lydia Avard, on February 2nd, 1876, with a globular tumour involving the whole of her right mamma, and extending into the axilla, on the inner side of which there were little hard nodules like peas. The tumour within the breast gland was freely movable under the skin and over the pectoral muscles ; the veins were distended over the tumour. Fluctuation was very distinct over the greater part of the swelling ; there was no discharge from the nipple, and the lymphatic glands were unafiected. In 1872 she first noticed an exudation from her nipple like glycerine ; soon after, a lump the size of a Avahiut appeared in her breast without pain, and the swelling increased. The breast would sometimes feel tense, but become relieved as soon as the discharge took place. For six weeks there had been no dis- charge. February 3rd. The patient having a little cough Chap. XVI.] Cystic Disease. 275 the operation was deferred until the 8th, when clilo- roform having been administered, an elliptical incision was made, and the whole tumour, with nipple and a portion of the skin, were dissected out and removed. The tumour was mainly composed of a cyst whicli contained about half a pint of mucoid fluid, and was lined by a thin, delicate, white membrane ; attached Mr- l> ^ W> v.^p-t*// \ \ \ti^pysjfi^^ I,} Fig. 10.— Cystic Duct Tumour with Pedunculated Intracystic Growths. Case 21. to its walls were several lobulated pedunculated tumours as seen in woodcut (Fig. ] 0). The growth examined showed a well-marked papillomatous structure. The processes are covered by long columnar cells, and often divide. Circular or elongated apertures lined by the same cells are also numerous. There are also small cysts with definite fibrous walls and colloid contents. The growth closely resembles that in Mrs. T.'s case, No. 20, and suggests that the large cyst in this instance is also derived from a duct. The small cysts in this growth have been formed, I suppose, by the 276 Diseases of the Breast. [Cnap. xvi. fasion of the processes in tlie manner described by Wilson Fox. Several small adeno-fibromatous tu- mours were also found on making sections of the gland in other parts of the breast. The arteries were twisted, wire sutures inserted, pressure was exerted by pads of lint, and tbe whole wound drawn together by strips of sti-apping. 21st. The wound has healed by first intention. Three years later the patient was well. Case 22. Cystic duct adeno^ma ; excision of tumour; cure. — Harriet W., aged 47, the mother of thirteen children, youngest six years, all of whom she had suckled, was brought to me on January 14th, 1867, with a globular tumour, apjiarently cystic, in the upper part of her left breast, which she had ob- served six months. At first she had a clear discharge from the nipple, but she had not had any lately. The skin over the tumour is apparently bound to the growth. Axillary glands sound. September 15th. Serous discharge from nipple very free ; increased by pressure. Tumour large. March, 1868. Tumour removed and found to be composed of a cyst, with inti-acystic pedunculated growth, which was pronounced by Dr. Moxon, after microscopical examination, to be adenoid. Case 23. Duct cyst of the hreast, following a contusion; intracystic flhro-cellular groicths ; rupture of cyst seven years later ; removal of breast ; recovery ; patient ivell twelve years later. — In 1860 Mr. Birkett saw a lady, aged 45, who for seven years had had some tumour in h-er right breast. In 1853 she received a blow in the part, which was followed by a flow of blood from the nipple. Two months later an abscess formed, and was opened, a cupful of matter escaping. The abscess healed, but some hardness remained, and occasionally a bloody fluid oozed from the nipple. At times half a pint would flow daily. Chap. XVI. J Cystic Disease. 277 Subsequently a soft tumour formed and grew, and the nipple retracted ; and two weeks before f:on8ulting Mr, Birkett the skin over the tumour ulcerated, and a quantity of blood and fluid escaped. When seen, a soft, vasc\dar, flocculent growth, very like everted mucous membrane, projected slightly from an opening in the integument, with which, however, it was "iiot connected, and from which serous discharge flowed. There was no pain. The nij^ple, which had been in- verted, was now everted. The axillary lymphatic glands were tender, but not infiltrated. Her general health was good. The whole breast was removed, and a rapid recovery followed. The patient twelve years later was well. A section through the disease exposed a cyst, with firm fibrous walls, embedded in adipose tissue. Three pedunculated masses of soft, vascular new growth were hanging from the cyst wall. From the nipple a bristle was passable along a duct into the cyst. The intracystic growth was comj30sed of fibre tissue, nu- cleated bodies of variable shapes, and a reticular struma with an arrangement like papillae or villi. The true gland tissue was nowhere visible. Case 24. Cystic duct sarcoma of the breast which never secreted viilk. — Mrs. G., aged 45, the mother of one child, aged 17, consulted me in February, 188i. She had suckled with her right breast, but not with her left because she had no milk in it, and the nipple was retracted. For six years she had had a discharge of a clear fluid from the retracted nipple of th left breast, and which at the catamenial periods was in- creased ; the fluid at times v/as like " treacle water." Three months ago this flow stopped and a lump appeared. A tumour the size of a walnut exists in the centre of the breast beneath the nipple. There is no dis- charge from the nipple. 1 advised incision and 278 Diseases of the Breast. [Chap. xvi. excision if necessary. Dr. Godfrey, of Balham, subsequently tapped the cyst and discovered a growth, the excision of which was advised, but not acceded to. Case 25. Cystic sarcoma of the hreast fourteen years ; removed ; well seven years later. — Mrs. B., aged 42, of Bottesford, Nottingham, consulted me in 1877 for a tumour in her left breast of fourteen years' duration. She was the mother of four children, the youngest being foar years old, all 01 whom she had suckled. At the birth of the last child, four years ago, the tumour was no larger than an egg. For the last six months it had grown rapidly, and is now as large as a fist. It is clearly cystic from its nodular shape and fluctuating feel. There is no discharge from the nipple. No lymphatic glands are enlarged. Ex- cision was advised and performed, and a good recovery followed. In 1884, seven years after the operation, the patient was well. Her maternal grandmother had died from cancer of the tongue, and her paternal grandmother from cancer of the breast. Case 26. Cystic sarcoma of the breast ; retracted nipple; excision; well eight years later. — Mrs. S., aged 50, the mother of nine children, one only of whom she suckled without difficulty, consulted me in March, 1876, for a tumour in her breast, which had been steadily increasing for two years. Eight of her children had died of phthisis at ages varying from fifteen to twenty-seven. When seen the tumour was the size of a fist, smooth, slightly lobulated, globular, and elastic ; it appeared to be cystic. The nipple did not discharge, but was retracted. The axillary glands were free. April, 1876. It was excised by Dr. Sams, of Blackheath, who sent me the specimen. April nth, 1876. Dr. Goodhart reported : "The tumour is spindle cell sarcoma or recurrent fibroid, as I expected from its lobulated appearance and manner t^ Chap. XVI.] Cystic Disease. 279 of growth. Tliey are not at all uncommon in the breast, and are often called adenoid growths from their very similar naked eye appearance. It will probably return in the cicatrix, though glands are less likely to be involved in the axilla." In ] 886 this lady was still well. Case 27. Cystic sarcoma of hreast ; rupture of cyst; ha',morrhage ; excision; recovery. — Mrs. S., aged 71, consulted me in January, 1873, for a tumour of the breast of twelve years' growth. It was then the size of a child's head. One cyst had ruptured, and an intracystic growth sprouted from its centre which bled freely. On this account an operation was ad- vised, and performed on February 26th, 1873. A good recovery ensued. The disease was on examination found to be one of cystic disease, with intracystic sar- comatous spindle-celled growths. This lady died, more than three years after the operation, in Sep- tember, 1876, from acute bronchitis. Case 28. Cystic chict adeno-sarcoma of the hreast of several pounds v:eight, as indicated by free discharge from the nipple, into which hcemorrhage had taken place; excision; recovery. — Mary A. W., a healthy looking single woman, aged 20, came under my care March 26th, 1861, with a tumour in her right breast which had been growing for three years and a half. It had commenced as a swelling the size of an Qgo^, which was situated in the centre of her breast, and had steadily increased without pain. When coming under observation the tumour was of the size of an orange, globular and tense. I diagnosed it to be of cystic origin. She disappeared from view for eighteen months, and when she reappeared the tumour mea- sured fourteen inches in diameter and twenty-two inches in circumference. It was globular, with the nipple in the centre ; quite movable with the breast, and uniformly elastic; fluctuation was readily to be 28o Diseases of the Breast. [Chap. xvi. detected in it. Tlie skin was much distended over the tumour, and on its outer side it was red and in- flamed from distension. The breast gland could not be separated from the tumour. The tumour during the interval mentioned above had grown slowly up to six weeks, when its increase became rapid. For three weeks there had been a free discharge of a bloody fluid from the nipple, which could be readily squeezed out by pressure upon the tumour. On March 15th I tapped the tumour, and let out a quantity of bloody serum and broken-down blood ; to allow of its more ready evacuation the opening was enlarged, when the finger, without force, easily broke up a large portion of the growth. Two and a half pounds of this material were thus taken away. The largest portion of the tumour was, however, of a more solid nature, which necessitated the removal of the whole gland. This was done, and a good recovery followed. A section of the tumour through its centre and the nipple showed a fine example of cystic sarcoma of the breast. At its lower part were many beautiftd examples of intracystic adeno-sarcomatous growths, which turned out of their cyst walls. About the centre of the tumour were smaller growths, infiltrated with blood, and breaking dowm ; and in the upper part there was little else than extravasated blood and clot. Microscopically, all the elements of sarco- matous tumours were present, spindle-cells being abundant ; there were, too, some glandular elements such as are found in adenoma. Case 29. Cystic sarcoma of the breast; rujyture of cyst ; ojoeration refused. — Clara W., aged 43, the mother of three children, the youngest being fourteen years old, consulted me on March 7th, 1867, for a tumour the size of an orange in her left breast, wdiicli Chap, xvi.j Cystic Disease. 281 had been growing thirteen montlis. It was glohular, semi-elastic, and nodular. The skin, nipple, and axillary glands were sound. April 7th. Tumour much larger ; its bossy surface is lost, and the growth seems to be one large cyst. Cyst tapped, and about one ounce of blood-stained fluid drawn off. June 2nd. Tumour size of cocoanut. July 8th. Tumour burst and discharged fluid largely mixed with blood. Operation refused. Intracystic growths visible ; later on some of the growths projected through the rupture in the cyst wall. July 16th, 1868. Patient sinking from asthenia and bleeding from the growth. Case 30. Cystic sarcoma of breast ; rwptiire of cyst ; operation rejected. — Mrs. R., aged 63, married at age of twenty-one and had five children, the youngest aged thirty. Nipple in left breast always retracted. Thirty years ago, independently of nursing, she had a tumour the size of a fist in her left breast, which dis- appeared after one year. She remained well for twenty-eight years, up to one year ago, when the sw^elling reappeared in the same breast, and this has gradually grown. At present (July 9th, 1873) a tumour the size of an egg exists in the upper part of the breast, which seems to be a cyst ; this is adherent to the skin. Ex- cision of the tumour was advised but not accepted. January 19th, 1874. The cyst, which has much increased in size, has ruptured and discharged its con- tents, a sarcomatous growth protruding from the skin opening. No operation was sanctioned. Case 31. Cystic sarcoma of breast; supjniratioib of a cyst followed by rupture of cyst ; no operation. — Mrs. C., aged 43, of Hull, the mother of five children, her youngest child being now fourteen years of age. 282 Diseases of the Breast. [Chap. xvi. After giving up nursing there was discharge from her nipple of a clear greenish or blood-stained fluid. Six months ago this discharge ceased, and the breast en- larged, inflamed, and suppurated. It was opened at that time by Mr. W. H. Rudd (April, 1883), and the abscess healed, leaving a lump. This increased in spite of treatment, and is now the size of a large Qgg. It appears to be (February, 1884) cystic. Incision into the cyst was advised, and excision of the lobe advised if growth was found. Nothing was, however, done, but the cyst burst and discharged bloody fluid, and discharge has been going on up to the present (October 12th, 1884). Case 32. Cystic sarcoma. — Mrs. S., aged 70, has had three children, Avhich she never" suckled. In 1875 she consulted me for a tumour in her right breast, which she had had four years ; when seen by me it was the size of a cocoanut, clearly cystic, and nodular. No lymphatic glands were enlarged. Skin normal. Operation not advised on account of age. Case 33. Cystic fibroma of right breast, with cystic degeneration of the gland ; excision of tumour ; cured. (Reported by Mr. Metzgar.) — Rebecca B., aged 40, was admitted into Lydia ward on June 21st, 1884, under JMr. Bryant's care. Patient's father and two brothers died of phthisis, and she frequently suffers from bronchitis and neuralgia. She is married, and has one son alive and healthy. Six weeks ago she noticed an uncomfortable swelling in her right breast, which appeared as a prominent tumour in the upper half of the gland. This tumour has not in- creased much since then, but it has seemingly got softer. On admission. The tumour is hard and nodulated, firmly embedded in the gland, but freely movable with it upon the pectoral muscles. The skin over it is normal. The axillary glands are not enlarged. Nip[)ie natural. Urine normal. Chap. XVI.] Cystic Disease. 2S3 June 24 th. Under chloroform an oLlique explo- ratory incision was made into the tumour. The tumour, when incised, ap])eared granular and fibrous, a fibroma ap])arently growing from or into a cyst ; the breast itself had undergone cystic degeneration. The tumour was then freely separated from the surround- ing breast tissue and removed. In so doing black cysts were seen spread over it. The vessels having been twisted, and capillary haemorrhage stopped by hot iodine sponges, three silk sutures were put in, and one and a half inches of drainage tube were inserted into the upper and left end of the incision, the lower or right half being well padded with lint and a sponge. The arm was strapped to the side. June 25 th. Drainage tube removed. 30th. Stitches removed. Lips of wound drawn together with waterproof strapping. July 11th. There has been good primary union. Tliere is very little discharge. A plug of terebene lint into the lower and right end of wound. 26th. Went out, to come up from time to time to be seen. This patient was subsequently quite well. The tumour when removed proved to be a fibroma growing from the walls of a cyst. The gland itself was full of small cysts, the result of degeneration. The temperature only on the occasions after the operation reached 100". Case 34. Recurrent mamviary cystic sarcoma ; excision ; well. (Reported by Mr. H. H. Wright.) — Eliza M., aged 36, was admitted into Lydia ward on July 14th, 1880, under Mr. Bryant's care. Patient is a married woman, and the mother of eight children. Three years ago she was operated upon for tumour of the left breast ; the tumour was removed, but the breast was left. She has since been able to suckle a child at the same breast. A year ago she noticed a small lump above the nipple which has steadily 284 Diseases of the Breast. [Chap. xvi. increased. On admission tliere was a large lobulated tumour involving the whole of the left breast, but divided into two chief parts. One- of these occupies the central and upper part of the gland ; the other, which is smaller, is placed on the axillary side. The whole tumour is above the level of the old cicatrix. It is freely movable, partly hard and partly elastic to the touch. One point above and to the inner side of the nipple is inflamed and painful. July 20th. Under an anaesthetic the whole breast was excised. The patient suffered a little from conjunctivitis after the operation, but otherwise did well, and on August 16th went out, the wound ha^dng healed. Description of tumour. — The tumour was every- where encapsuled. It was composed of many lobules, separated from one another by fibrous septa, and each enclosed in a capsule. Some of them grew into thin- walled cysts containing little or no fluid, theii' walls being in contact. The growths in these cysts were in some cases lobulated finely on the surface. In a few, they resembled in colour and smoothness a mucous nasal polypus, but were in consistence a little firmer. The majority of the lobules showed on section a finely lobulated appearance, the outlines of the little lobules being crenulated, and some having a distinct cavity in the centre. IS'o communication could be traced be- tween the various cysts, nor could any be traced di- rectly to the nipple. Some parts of the growth were hard, firm, and fibrous. There were no blood cysts, nor any of the translucent looking material so common in a sarcoma. In some of the nodules (felt elastic during life) tliere were many elongated slit-like spaces with smooth walls, the surrounding material being acinous. Histologically the tumour was composed of spindle cells and gland elements (adeno-sarcoma). Case 35. Cystic {duct) sarcoma of right hreast ; Chap. XVI.] ■ Cystic Disease. 2S5 earhj symptom hainorrhage from nipjiJe ; amputation. (Reported by ]\Ir. Phillips. ) — Eliza A., aged 45, a gover- ness, was admitted into Lydia ward on January 8th, 1884, under Mr. Bryant's care. Patient was delicate, but never had any particular disease. Breasts have been always tender, but no history of injury. Men- strual periods regular. In January, 1883, one year before admission, patient first noticed a pale brownish discharge from \ the right nipple. It lasted three months, and was 1 ^ increased during her menstrual periods. In March she noticed a lump, the size of a small marble, on the upper and inner part of her right breast. This in- creased visibly during her menstrual periods. About two months ago it began to grow, and since then her menses have been irregular. On admission. Patient is a florid-looking woman, and apparently healthy. The upper and inner aspect of the right l3reast is occupied by a "firm but not liard " lump, measuring 2i x 14 inches, and with the longest axis vertical. The lump is painful. There is no fluctuation. The skin is not very movable upon the growth. A liard cord can be felt running down from the growth to the nipple. During pressure upon the tumour a few- drops of serous fluid mixed with blood came from the nipple. Under the micro- scope this fluid was found to consist of blood corpuscles forming rouleaux. A small gland the size of a nut exists in the axilla. The breast was removed, and found after removal to have been the subject of cystic degeneration of the gland. Into some of the cysts sarcomatous growth of the spindle-celled variety existed. Plate VIII. Fig. 5 was taken from this case. 19th. There was primary union all down the wound except at its lower part. The uppermost stitches were taken out. 286 Diseases of the Breast. [Chap. xvi. 26 th. Drainage tube taken out. February 1st. There is perfect union of woLind. 9th. Discharged well. The temperature ran a normal course throughout. . Case 36. Cystic adeno-sarcoma of hreast; excision. — MissC.,aged 46, consulted me on July 10th, 1885, for an affection of her left breast, which had been coming on for about six months, and was accompanied with some pain. The whole gland seemed to be indurated and enlarged, and to the hand felt coarse and nodulated ; below the nipple a hard mass was felt. The nipple was natural, and discharged a blood-stained fluid, more particularly after manipulation. The skin over the breast was natural, and the lymphatic glands were not enlarged. On July 11th the breast was excised, and a good recovery ensued. To the eye the breast was clearly undergoing cystic degeneration, the whole gland being full of small cysts. In one lobe these cysts had much in- creased, and one of them contained an intracystic growth. The cysts had evidently a connection with the ducts, since during life there was a nipple dis- charge, and after the removal of the gland fluid could be squeezed out of the nipple. ]\Ir. Symonds' report on the case is appended. Report of case hy 2Ir. Symonds. — The breast was found to contain a large cyst in the tissue just beneath the nipple, measuring one inch across. Projecting into one end of the cyst was a rounded solid growth, with an uneven papillomatous-looking surface. This extends beyond the limits of the fluid- containing portion of the cyst as a solid cylinder, round which the cyst wall is closely fitted, so that in a transverse section the appearance is much that of a large vein filled with a growth. The section has a whitish-grey colour. No other cyst of any magnitude was seen, Chap. XVI.] Cystic Disease. 287 l)ufc there were many small ones. The rest of the l)reast looked fairly healthy. The tissue was hard, but no definite tumour was visible. Microscopic examination. — The solid growth is composed of irregular glandular acini, lined by short columnar cells, with a deeper layer of a less regular form. In many places the cells are heaped up, and then are smaller. The stroma is composed of line fibrous tissue, and contains here and there a cavernous arrangement of vascular tissue. It is very delicate in parts, and forms but a small portion of the whole ; in other places, however, especially where the growth is connected with the wall and out- lying breast tissue, there is much solid material. Tliis contains much fibre tissue, spindle, and a few myeloid cells, and closely resembles a sarcoma. This solid growth does not form a separate tumour in the breast, for at no great distance from the cyst wall the ordinary mammary tissue is reached. Such a structure as that described might be looked upon as the starting point of the growth, but it forms so small a part of the whole, and reaches so short a distance into the breast tissue proper, that the view seems not so reasonable as the one stated below. The cyst wall is lined with the same short columnar cells. There are other cysts visible under the microscope varying from a size slightly larger than a normal acinus to "Ith inch across. The smallest are evidently dilated acini and ducts. These are lined with rounded or columnar cells, according to their source of origin. The larger ones, of which two or three were found, con- tain, besides the granules, larsje round or oval cells with nuclei, and these cysts are lined by peculiar large cells. They exhibit an intracellular and intranuclear network, have a more or less columnar shape altered by pressure, and large prominent nuclei. They are set dii^ectly upon a wall of close fibrous tissue containing 288 jD/seases oe the Breast. [Chap. xvi. elongated nuclei. In places these cells are heaped up and proliferating. They are undoubtedly the pro- genitors of the large granular cells found in the cysts. Sometimes cells of this character are found filling spaces in the glandular formations, and show- ing in gi-eat contrast to the dark, short columnar cells, for they are themselves pale^ except for the nucleus and granular appearance. In these smaller cysts there are also found glandular growths, connected with the wall. Where attached to the wall there is no solid growth in the neighbouring breast tissue. So far as the description has been carried, it will appear that there is no solid growth except that found in the cysts. Examining other parts of the breast, it is found that everywhere some change is going on, that there is a widespread activity manifesting itself throughout the entire organ, culminating in the formation of cysts and glandular growths. Again, it umst be stated that nowhere is any highly nucleated tissue to be found except on the margin of the large cyst above referred to. The fibre tissue is dense, and contains few nuclei, and everywhere fat is found, so that in all the illustrations adipose tissue, where not sketched, will be considered to be present close to the acini. The presence of the fat seems a good evidence of the fact that we are dealing with a diffused change in the breast, and not with a widely disseminated tumour, a point insisted upon by Cornil and Ranvier. The first departure from the normal structure is seen in the acini. The cells are increased in number and obscure the lumen, and the wall shows as a thickened fibrous investment, with very few nuclei. ISText several acini fuse together by obliteration of the intervening septa, a process seen in all parts of the breast in A'arying degrees. The cells are smaller Chap.xvi.i Cystic Disease. 289 and more irregular tlian the normal ones. In some places, but this is exceptional, fibrous tissue is produced at the same time, and we have the aj)pearances of an alveolated stroma of fibre tissue, the spaces of which are filled with epithelial cells. In the centre of some spaces is seen a lumen, while in others the cells have accunmluted to such an extent as to obliterate all trace of it. Such are the various morbid appearances seen in this breast. The sequence of e^'ents it is not so easy to arrange, for though there are some small adeno- matous growths in cysts, I cannot follow the develop- ment of such out of the earlier changes detailed above. It is important to compare this case with the sketches of the breast from Mrs. T. (case 1), where a pure cystic change is seen, and wdth that of Mrs. T. (case 20), where a pure adenomatous growth hangs by a pedicle to the wall of a cyst. Whatever view be taken of the sequence of events in this breast, the following conclusions seem justified : 1. That the change is a general one. 2. That there is no new solid formation outside of cysts. 3. That the departure from the normal begins in the epithelium of the ducts and acini, and proceeds either towards cyst formation or fusion of many acini, to one or to both of which changes new formation of gland tissue succeeds, It may, I think, also be surmised, when we con- sider the appearances presented by the large cyst in case 1, and the connection between the intracystic growth and the cyst wall in this case, that the glandular formation arises by outgrowths from the cyst wall, and is a pure intracystic growth, and not a protrusion inwards of a tissue formed outside the acini and ducts. As in cases 17 and 20, the growth may be viewed as an adeno-sarcomatous ])apilloma. T— 2.5 290 Diseases of the Breast. [Chap. xvi. Case 37. Cystic sarcoma of right breast; uIceixLtion of skin over it; excision; recovery. (Reported by Mr. H. Dismorr.) — Dora G., an anaemic-looking woman, aged 5-3, was admitted into Lydia ward on December 16th, 1873, under the care of Mr. Bryant. She had noticed for many years in her right breast a lump, at first not larger than a nut. Her sister, while in bed, had put her elbow on the patient's breast whilst raising herself up. This gave her a great deal of pain, and the small lump then ap- peared ; it gradually increased in size, but did not trouble her much till about six weeks before admis- sion, when she caught cold, and it enlarged rapidly ; the skin broke in two places over two prominent lumps ; the bridge between them gave way and united the separated sores ; these increased in size and discharged very much. On admission, the breast was the seat of a tumour the size of a cocoanut, which was somewhat nodulated on the surface ; the skin on the inner side of the nipple was red from capillary congestion ; on the outside there was an ulcerated surface five inches by four, which was in great part covered by a blackish slough. The edge of the skin, though adherent to the tumour, was not infiltrated by new growth. The glands in the axilla were enlarged, but there was no enlargement of the abdominal viscera, and the other breast was healthy. On December 23rd she was put under the influ- ence of chloroform, and the tumour was removed by two semi-elliptical incisions, with the enlarged axillary glands. The two edges of the wound were brought together and supported by strapping. There were no adhesions of the tumour to the deeper parts. A sec- tion of the tumour showed a large single cyst with definite walls, its cavity being filled with sessile growths of a lobulated form, tough consistence, and ciiap.xvi.i Cystic Disease. 291 •n'.latiiious look. The microscope showed it to con- sist of a loosely fibrillatecl connective tissue spindle- celled sarcoma and a larger number of round fatty nuclei scattered through it. After the operation a morphia injection was given, which greatly relieved the patient, but she was very sick the day after, and perspired freely for some two or three days. 29th. The wound is looking very healthy, and covered with granulations. There has been a little diarrhoea, accompanied by pain in the abdomen. Temperature 98-6°, pulse 78. January 17th, 1874. The patient has gone on improving; there has been a good deal of perspira- tion, at night particularly, after which she complained of weakness, but her appetite has been good. Six pieces of skin were transplanted to the wound, four of which seem to have taken. She gets up for an hour or two in the day. The wound decreased in size, and on the 27th. was the shape of a triangle, each side being about two and a half inches long. 29th. Eight pieces of skin were transplanted, six of which were thought to have taken five days later from this time. She went on capitally, and left the hospital on February 9th, the wound having less- ened in size half an inch in ten days. This patient was known to have been well three years later. Case 38. Cystic carcinoma of breast ; excision. — Miss S., about forty-fi.ve years of age, consulted me on December 19th, 1884, on the advice of Mr. Bisshopp, of Tunbridge Wells, for a tumour involving her right breast of more than two years' growth. She was first seen by Mr. Bisshopp in November, 1882, when the tumour had been discovered some months; It was then hard, but painless ; it grew gradually. When I saw her the whole breast seemed 292 Diseases of the Breast. [Chap. xvi. to be involved in the disease, and was hard and nodular. The nipple and skin over the breast were natural. I regarded the case as one of cancer, and advised its speedy removal. Sir James Paget saw the case and gave a like opinion. On January 9th, 1885, the operation was performed, aud the wound healed at once by quick umoh. The lady is now (two and a half years after the operation) well. Report of tumour hy Mr. Syinonds. — The tumour was situated beneath the nipple in the substance of the breast, and measured about one and a half by two inches. The section when fresh showed a pinkish colour, with many yellow spots resembling altered secretion, plugging ducts. There were, besides, many larger spaces with smooth walls filled with a yellowish- grey or darker thick fluid. The tumour was not limited by any capsule, but blended directly with the breast, and in some places wdth t]]e adipose tissue. When a thin slice was cut and the yellow contents of the spaces removed, the whole closely resembled caver- nous tissue, so numerous were the spaces and so scanty the stroma. Examined microscopically in water, the yellow material was found to be composed of cells of all shapes and in all stages of degeneration, the j^re- vailing shape being an irregular columnar. Numerous fatty granules, and plates and rounded or irregular masses of carbonate of lime also were present. The microscopical appearances are shown in the drawing below (Fig. 11), made under a low magnifying power. The spaces are of various sizes and shapes, are all of a tubular character, and most of them have a distinct lumen, occu]»ied when fresh by the yellow material above described, and which has nearly all fallen out in the preparation of the section. The epithelium lining these spaces is arranged mostly in a double or triple layer, having a distinct dark line where, uniting, Chap. XVI, Cystic Disease. 293 tlicy limit the luinen, an appearance resembling the striated border of Briicke. In other spaces the epi- thcliuiii is more abundant, and forms irregular eleva- tions projecting towards the lumen, which is in some \ k ,_ the whole gland had better be extirpated, for all proliferating cysts are prone to grow, and the breast glands of such as contain them are rarely only locally implicated. I have, on many occasions, after the removal of a cystic sarcomatous tumour, found such portions of the gland as seemed to be healthy, the seat of the same same disease only in miniature (case 21), and this fact faiiiy suggests that the disease, although palpable in one part and apparently local, is really a general gland disease, and that under such circumstances the whole gland had better be excised. In the more solid forms of cystic sarcoma and cystic carcinoma, early excision is a rule of practice which should never be deviated from. CHAPTER XYII. GALACTOCELES AND HYDATIDS. Milfe. or lacteal cysts or galactoceles are com- paratively rare cystic tumours of the breast. They form when the gland is in a state of functional activity, and usually during the first three months of lactation. Exceptional cases are met with which ap- pear at an earlier as well as at a later period, I shall record one which appeared during the ninth month of lactation. Atlee published in the American Journal of Med. Science for April, 1874, an example which developed sixteen months before childbirth, and in- creased rapidly during preg-nancy; and Bouchacourt, as recorded by Richelot, has reported an instance which Cliap. XVII.) GaLACTOCELE. 3II occurred in a woman, aged 51, twenty-four years after lier last confinement. As indicated by the name, the cysts always contain milk, cream, or a buttery material, which is clearly the product of milk ; and these variations in the cha- racter of the cystic contents are manifestly due to the changes which the fluid undergoes after it has been extravasated into the gland. At times the tumour follows a blow or some inflammation, but as a rule it appears without any known CAUse during full lactation. The tumour is. doubtless generally due to a rupture of the milk ducts, and consequent extravasation of milk into the con- nective tissue of the gland, although in some cases it may be caused by the obstruction and subsequent dilatation of a lacteal duct. In one case the tumour will increase rapidly in size, and Birkett states that it may increase rapidly and distinctly during every time the infant sucks. In another it may appear suddenly, increase slowly, and then, as far as size is concerned, either remain stationary or even diminish, the diminution in size being occasioned by the absorption of the watery con- stituents of the milk, and its consequent concen- tration. With respect to size, cases are on record in which several pints of milk have been evacuated. Scarpa is reported by Forget to have recorded an instance in which two pints of milk were removed from the tumour; and Birkett gives another from which, after excision, ten ounces of thick cream flowed away. In the Guy's Hospital museum there is a prepara- tion (2290-*^) of a large cyst which Mr. Birkett removed from the breast of a married lady, 27 years of age, which had been increasing for eight years. The cyst contained fluid composed of milk and serum, and in the walls of the cyst were several small adenomatous 312 Diseases of the Breast. [Chap. xvii. growths. It is probable tliat those gro^i^hs were secondary to the formation of the galactocele. At the same hospital (Preparation 2290-5^) there is also a breast removed from a middle-aged patient, for a tumour containing cheesy matter, occasioned by obstruction of a lactiferous tube. A thin translucent membranous expansion exhibits the boundary of the cyst, but all the contents have been removed. The tubes of the gland generally appear dilated, and pieces of glass rod are placed therein. There is no duct at present traceable to the cyst. The signs and sympioms of this affection are more negative than positive. The one positive sign is the presence of a more or less globular swelling in a breast which is performing its physiological functions with full activity ; one that may increase rapidly, or on the other hand, very slowly, and that gives rise to trouble mainly from its size. If it causes pain, it will probably do so from its weight. If it is attended with external evidence of venous congestion, as indicated by full veins, it will be so on account of its size. When the contents of the tumour are liquid, there will be fluctuation. When the fluid has been partially ab- sorbed, and the contents are as it were condensed, the tumour will yield a doughy and peculiar feel. When the contents have become desiccated and a cheesy mass is left, it will present more the physical features of an adeno-fibroma or sarcoma. When it occurs during the period of suckling, and the child is put to the breast, pain is often produced. " The pain and distension (of the cyst) being increased by the draught of milk which enters the breast so soon as the child begins to suck " (Sir A. CoojDer). Should the lacteal cyst occupy the posterior part of the gland, and consequently be covered in front with a thickness of breast tissue, the globular swel- ling of the tumour will be obscured, and it may feel Chap. XVII.] GaLACTOCELE. 3T3 nodulated, the coarse, active gland tissue surroundiiig the cyst giving rise to this condition. Tlio nipple is not affected in this trouble, although at times it may discharge milk. When this symptom is present during the lactating period it is of no value, but when it exists after the breast has ceased this function, it is of great use ; since it fairly shows that the cyst contents communicate directly with a duct, and thus suggests the diagnosis. At times the tumours are multiple. I have seen two in the same breast. In this case the tumours were of the size of small eggs. They had appeared two years before I saw them, during lactation, and had for one year steadily diminished in size, even to a half, but since then they had been stationary, but felt doughy to the touch, and could be moulded to a degree like clay ; that is, the side of one of the tumours could be made Hat or convex by pressure. The second tumour could not be so altered, but it was placed more deeply in the centre of a lobe, and had the feel of a fibroma. I cut into both tumours, and evacuated from one what might have passed as excellent clotted cream, and from the other a cE'eesy material, which represented the cream still more condensed. This case was in a lady about 35 years of age, and the tumours had appeared during the lactation of her first child, two years previously. A cystic tumour of this kind may therefore de- crease in size, from absorption of its fluid contents, and as it decreases become more solid. Treatment. — These cases, when met with in the months of early suckling, or when that function is in full activity, are not to be allowed to drift, for the milk will not be re-absorbed, and if re- absorption does not take place, the increase of the tumour may be expected as long as the functional activity of the breast continues. It is wise, therefore, 314 Diseases of the Breast. [Chap. xvii. should the swelling be large, to take the child away from the breast with the hoj)e that with the disappear- ance of the secreting action of the gland, any increase of the tumour will be prevented, and its decrease encouraged ; when the cyst is small suckling may be continued. Should this decrease in size not ensue, the cyst should be aspirated and its contents drawai off. Should it then refill and the operation prove unsuccessful, an incision should be made into the cyst and its contents evacuated. The incision should be a free one, for if a small one be made, it will soon close, and a re-accumulation of milk will take place, or a milk fistula will be left. This milk fistula will last as long as the breast is active, and cease to discharge only when secretion has stopped. The more chronic cases are to be treated as those of simple cysts, that is, by a free incision, the evacu- ation of the cyst contents and the subsequent closure of the cyst cavity by granulation. In the case recorded, where solid contents existed, this method of treatment was successful. In the following case, where the fluid was cream-like, a similar result ensued. Galactocele follovned hy pregnancy and suckling of child from affected breast. — Susan T., 35 years of age, who was confiiied thirteen months previously, and suckled for ten months, came to me on October 5, 1865, with a globular tense swelling, the size of an orange, in her right breast, which had been coming four months, that is, from the sixth month of lactation. On November 20 the tumour was punctured for diag- nostic purposes, and then freely opened, at least six ounces of cream exuding. A good recovery ensued. On September 25, 1866, this patient again came to me when she was pregnant nine months. The breast was then apparently quite healthy. She was confined on October 4, and suckled well. No breast trouble foUowinof. Chap. XVII.] GaLACTOCELE. 315 Galactocele of eleven years' standing, suppurating after fourth confinement ; treated by free incision and cure. — Annie S., aged 31, the mother of four cliil- drcn, the youngest being nine weeks old, came under my care on April 1, 1874, with a tumour in the up[)er i)art of her right breast, wliich measured tliree and a lialf by two and a half inches in diameter. The skin over the tumour was adherent to it. The nipple was retracted. Thirteen years before, when only 1 8 years of age, after a blow, she had pain in her right breast ; two years later she married ; when suckling her first child she noticed a small lump, the size of a walnut, on the upper part of her right breast. This never left, but after each of her confinements (four) increased in size. Between the periods it remained stationary. After her last confinement, nine weeks before ad- mission, the lump increased rapidly, became pain- ful, inflamed, and suppurated, some ounces of pus escaping. She had never been able to suckle with the right breast, as the nipple was too flat. A galactocele being diagnosed, I made a free incision into the tumour, and turned out a cupful of cream-like fluid, after which the cavity closed and recovery ensued. Treatment.— The operation required is a free inci- sion into the cyst in a line radiating from the nipple, followed by the thorough evacuation of the contents of the cyst and its perfect cleansing with iodine, or other antiseptic lotion. The cyst should subsequently be plugged with iodoform, carbolic, or other gauze, to ])romote healing by granulation. The cyst wall might, in very chronic cases, be well sponged with a twenty- grain to the ounce solution of chloride of zinc, or with the pure tincture of iodine before plugging. The wound should be left o^qa\ to heal from below. 3i6 Diseases gf the Breast. [Chap. xvii. Hydatids ix the Breast. These cysts are found occasionally in tlie breast gland, as tliey are known to occur in any other part of the body. How they get there is a question which need not be discussed in these pages. When such a cyst appears in the breast, it does so as a single, painless, tense elastic globular swelling of some portion of the organ unassociated with any morbid condition of the breast gland or nipple, or parts over the breast. It gives trouble merely mechanically by its size. After a period, and, it must be written, a very uncertain period, the hydatid will die, and under these circumstances the parts around will inflame and suppurate ; the abscess eventually, if left to nature, opening and discharging; the dead wall of the hydatid in this way escaping. Indeed it is by the escape of the dead entozoon that the true nature of the case is sometimes for the first time revealed. These cysts have been found in women of ail ages, from twenty-three upwards. They grow slowly, at times very slowly ] in two of the cases I record the tumour had existed for eight and eleven years re- spectively. In exceptional cases they attain the size of an orange rapidly. They are without doubt diflicult to diagnose from cystic disease of the breast, or some neoplasm, and more particularly when they are small These tumours are, however, always single, and attain, a larger size than most cysts ; they are never associated with dis- charge from the nipple. Their true nature can, how- ever, be readily made out by an exploratory puncture, and an examination of the fluid drawn off". The fluid of the hydatid being clear, or very slightly opalescent, alkaline, sp. gr. 1007 or 8, and 7zo?i-albuminous ; whereas the fluid of most^ if not all, gland cysts is PLATE VIII. Fig.l. Fig. 2. n^ Fig. 5. v^ Fig. 3. Fig. r vi I' -*..^ >^ 1 1. Lipoma. ■ 2. Chondroma. 3 & 4. Hydatids. 5, Cystic Degeneration of Breast with sarcomatous Growths. Chap. XVII.] HyDA TIDS. 3x7 albuminous. When the characteristic hooklets are found in the fluid the diagnosis of any case is certain. Should the cyst hold a superficial position in the gland, its globular outline will be readily recognised ; in the case from which Fig. 4 on Plate VIII. was taken, this point is well illustrated. The case was one which occurred in the practice of my colleague, Mr. Symonds. Hydatid of the breast. — Mary A. H., aged 30, a widow, came under my care at Guy's Hospital, in October, 1865, with a smooth, globular, fluctuating swelling, the size of a cocoanut, occupying the upper half of the left breast. She was a healthy woman, the mother of three children (the youngest being eight years old), all of whom she had suckled. The tumour had been growing for five years, and had appeared as a small hard swelling, the size of a nut, above the nipple, and apparently deeply seated in the gland. It had gTOwn steadily, although during the last twelve months its increase had been more rapid. It had never caused any pain, and had troubled her chiefly on account of its size. The tumour and breast seemed to be one, and the gland moved freely over the deeper parts. The nipple was natural, and the skin over the breast was not implicated. There were no enlarged lymphatic glands. The diagnosis, in this case, was not easy; the swelling was evidently cystic, for all the symptoms indicating a cyst were well marked. The history of the case, and the almost total absence of pain and of all such symptoms as generally indicate suppuration, went far to prove that the swelling was not due to the presence of a chronic abscess. The nature of tlie swelling, and the apparently perfect healthiness of the uninvolved portion of the mammary gland, with the absence of nij^ple discharge, contra-indicated the tS Diseases of the Breast. [Chap. xvii. presence of ordinary cystic disease of the breast. The origin of the swelling, as a small tense turnour^ and its gradual and painless enlargement, unaccompanied by any definite symptoms of disease of the mammary gland, were indications enough to excite a suspicion of its hydatid nature, but the extreme rarity of such an afiection forbad any positive diagnosis being made. I therefore punctured the cyst with a trocar and cannula, and drew off a few drops only of a thin watery fluid containing flocculi of a delicate membrane, such as was at once recognised as the lining membrane of a hydatid cyst. On this diagnosis a free incision was then made into the tumour, and out came a large parent hydatid cyst, with many daughter cysts. The whole measuring seventeen fluid ounces.* Under the microscope, micrococci were clearly seen, and the diagnosis established. The cavity from which the hydatid escaped was left to granulate, and in three weeks the woman was well. I have given this case in full, with some remarks I made with reference to diagnosis, when I originally showed the hydatid tumour to the Pathological Society on Nov. 7, 1865, for it contains within itself an epitome of the history and progress of all similar cases, and likewise illustrates the line of treatment which should be adopted for diagnostic as well as curative purposes. In 1866 a woman was admitted under the care of Mr. Hutchinson, into the London Hospital, for some injury. It was then found that she had been twenty years before in Guy's Hospital for some breast trouble, and that a healthy cicatrix existed on the site of her right breast. Mr. Birkett, to whom Mr. Hutchinson then referred, found that this woman had been in 1846 a patient of Mr. Bransley Cooper, who had removed ■* Prep. 22D1-5, Guy's Hosp. Lluseiiin. Chap. XVII.] HyDA TIDS. 3 T O her breast for a sni)posed tumour, wliicli turned out to be a hydatid. The woman, when under Mr. Cooper, was a widow of 51 years of age. Slie had had a swelling in her breast for eleven years, and for eight it had been pain- less ; for the last three years it had caused her incon- venience, probal)ly from its size. It was about three inches in circumference, firm, and apparently solid. On this account the breast was excised. After its removal its hydatid nature was discovered. The woman made a good recovery. In the Guy's Hospital museum there is a prepara- tion (2291) taken from a patient of Mr. Cooper Forster's, which supports the points illustrated by my own case. It was removed from a married, prolitic, healthy woman, aged 29, in the year 1856, who, six years previously, had observed, when she was only 23 years of age, and whilst suckling her first child, a small hard pea-like swelling in the axillary lobe of her right breast. It was painless, and had increased slowly. When ad- mitted into Gruy's the tumour measured four inches in diameter, and was hard and elastic, but fluctuation could not be detected in it. It moved freely with the breast. Manipulation caused pain. It was explored by an incision, and the parent cyst, containing daughter cysts and limpid fluid, escaj)ed. A good recovery ensued. Fig. 3 on Plate VIII. illustrates the case. Occasionally, as already stated, these hydatids die, and when they do, they excite irritation, inflamma- tion, and suppuration. Suppuration is in a measure curative, since it is the way nature adopts to get rid of its unnatural lodger. In Prep. 229 lio, Guy's Museum, a hydatid dis- charged by suppuration maybe seen; it occurred in the practice of Mr. Birkett, and I had the advantage of seeing the case, the details of which are as follows: 320 Diseases of the Breast. [Chap. xvii. Hydatid in the breast; su^Dpuration ; cure. — A married woman, aged 24, was admitted into Guy's in November, 1866_, under the care of Mr. Birkett. She looked delicate, but stated that she had always enjoyed good health. She had, four years j)reviously, given bii'th to dead twins, and had not since been preg- nant ; suckling, therefore, had never occurred. Eleven months before admission she accidentally discovered " a small lump " on the sternal half of her left breast, which slowly enlarged, but was unattended with pain, until about three or four months since. A month before admission the skin over the tumour became red, the tumour itself became larger, and more prominent ; for the first time also it became painful. When admitted the whole of the sternal half of the left breast formed a tumoui*, the skin covering which was red and painful when touched. The out- ward appearances were those of slow inflammation preceding suppuration, the skin here and there having a purple congested hue. After a few days, fluctuation in the tumour was clearly felt, and the skin began to ulcerate. Four openings altogether appeared, the largest being about half an inch in diameter. Thin, but fairly good pus escaped from the apertures for three or four days, when the nurse, as she removed the dressing, discovered the yellowish-white hydatid membrane, which had escaped from the largest opening in the breast, lying upon the dressing. After the escape of the hydatid the opening in the integument soon healed. This case is an excellent one to illustrate a method that nature occasionally adopts to get rid of a hydatid cyst. In the present case the cyst was in the breast, but the method of cure would have been the same in other parts. Had the true nature of this tumour been understood, a more rapid cure would have been brought about by a free incision. ciiap. XVII.] Hydatids. 321 By way of summary it may be stated tliat hydatid tumour of the breast is generally discovered by acci- dent, as a small, hard lump, eml)edded in one of the lobules of a healthy adult woman ; that it increases, as a rule, slowly and iKiinUssly., and gives trouble solely by its size. As it grows it becomes so identified with the breast tissue as to move with the gland, and to appear as part of its structure. When it has attained the size of an egg, the sensation of fluctuation may be detected in it, and however much the integument may be raised by the tumour, it will always maintain its healthy appearance. At an uncertain period of the cyst's life the tumour will become the seat of a subacute or chronic in- flammation, which will end in suppuration, with the eventual discharge of the hydatid, and the cure of the case. The period at which this result will ensue is, however, too uncertain to base a treatment upon. From the process employed by nature we can, how- ever, learn our lesson as to treatment, and turn the cyst out of its bed through a free incision as soon as a diagnosis of the case has been made. The cavity in which the hydatid rested will, on its removal, rapidly contract, and a recovery take place. For diagnostic purposes in this as in the other cystic tumours to which attention has been directed, the use of the exploring needle cannot be too strongly advocated ; for by it, and it alone, can the true nature of the case be at once made known. Sir A. Cooper originally described these cases, and illustrated them in his work on the breast (1829). Haussmann of Berlin has recently given a good description of them,* * Medical Times and Gazette, vol. ii. : 1874. 322 CHAPTER XVIII. A SUMMARY OP THE DIAGNOSIS OF TUMOURS OF THE BREAST. To help the practitioner on the question of diagnosis of a mammary swelling, the following conclusions have been drawn up, which it is hoped may prove of assistance. 1. Tumours that arise during lactation are pro- bably milk tumours, i.e. galactoceles or inflammatory swellings and abscesses. 2. Tumours that are found to be in, but not con- nected with the breast ; that can readily be made out to be distinct from the gland, and moved without causing dragging upon the nipple, are jDresumably of the benign kind. If they are of slow growth, hard, inelastic, and lobulated, they are probably of the adeno- fibromatous variety ; if of more rapid growth, smooth, somewhat elastic, and only slightly lobulated, adeno- sarcomatous ; and if hard in parts, and soft in others, clearly fluctuating and bossy, they are probably cystic sarcomatous growths, or colloid. 3. A tumour that infiltrates a lobe or lobes of the breast, which cannot be separated from the gland and has no distinct boundary, is in its nature either inflam- matory or cancerous j the lobe or lobes affected being in one case infiltrated w^ith inflammatory products, in the other with epithelial elements. 4. When the afifected breast has been physiologi- cally active, or the seat of injury; when the swelling is ill defined and the mammary gland feels leathery, or Y^ainful and elastic, and when more than one of its lobes is separately involved, the probabilities of the aflfection having an inflammatory origin are very ciiap. XVIII. 1 Diagnosis of Tumours. 323 great ; altliough when the infiltration has attacked an inactive or obsolete breast, appears as a single tumour, is hard, and nodular, the prospects of tlie tumour being cancerous are reasonable ; and when, in addition to these special local symptoms, there is either "dimpling," "puckering," or infiltration of the skin over the tumour, or the tumour with the breast is fixed to the deeper structures, the diagnosis of cancer is conhrmcfl. 5. Any globular, smooth tense tumour, situated within and apparently forming part of a breast, should be suspected to be of a cystic nature, and when the tumour is associated with a discharge from the nipple of a clear or blood-stained serum this suspicion is much strengthened. 6. When more than one globular swelling is pre- sent, or the breast feels coarse to the hand, the gland is probably the seat of cystic degeneration or of involution cysts. When the tumour is single and there is no nipple discharge the tumour is either a chronic abscess, a serous cyst, or a hydatid. 7. When the tumour is punctured for diagnostic purposes, and the fluid withdrawn is brown, mucoid, blood-stained, or blood, the cyst is probably of duct origin ; and in proportion to the amount of blood in the fluid is the diagnosis of an intracystic growth to be made. 8. When the fluid is clear and albuminous, the cyst is probably serous ; when watery and free from albu- men it may with confidence be pronounced to be hydatid. Under these circumstances the character- istic booklets will be found in the fluid. 9. A slowly growing tumour, which has shown no signs of inflammation in its origin and progress, that eventually becomes the seat of inflammation as indi- cated by local redness, swelling, heat, and pain, may be either a suppurating hydatid tumour, or a gum- matous or tuberculous inflamuiation of the breast. 324 Diseases of the Breast. [Chap. xviii. 10. A solid or cystic tumour, however large, that simply distends the integument over it and has no tendency to infiltrate it, is clearly a solid or cystic adeno-fibromatous, or adeno-sarcomatous growth. 11. A solid or cystic tumour, however small, that gives rise either to dimpling, puckering, or infiltration of the skin over it, becomes fixed to the deeper tissues and is complicated with enlargement of the axillary or clavicular lymphatic glands, is certainly a cancer. 12. A flattened or retracted nijjple associated with a tumour may be a symptom of small or great signifi- cance. If not congenital in its origin, or due to some antecedent inflammation, the flattened condition of the nipple may be brought about by a simple stretching of the gland, the result of continued growth of a simple neoplasm, whereas the re^:actio2i of the nipple may be produced either by tlie contraction of a .scirrhous, tumour infiltrating the lobe of the breast, an^ dragging upon its ducts, or by the presence of some adenoid, sarcomatous, or cystic tumour in the centre of the breast, and so separating its ducts as to bring about a drawing in and retraction of their ter- minations. 13. A tumour that ulcerates upon its surface and becomes excavated by the extension of the neci'otic ulcerating process, is most probably cancerous, and when the edges of the ulcer are raised, indurated, and everted, the diagnosis is confirmed. 14. A tumour that presents a prominent fungating mass from some parts of its surface, and this mass projects from an orifice which has punched out and not infiltrated edges, is certainly sarcomatous, and probably cystic. A slow growing tumour which first stretches the skin and then ruptures it, and from the orifice of which thus made a colloidal or mucoid fluid escapes, is probably a colloid tumour. Chap. xviii.] Diagnosis of Tumours. 325 15. A tumour wliich originated in the breast, that becomes complicated with a red or wliite, brawny, (Edematous or tuberculated condition of skin over the growth is witliout doubt cancerous and of the worst type. 16. The absence of any enlargement of the axil- lary, or clavicular lympJiatic glands with any breast tumour is an argument in favour of its benignancy, whereas the presence of such a complication suggests the reverse. Enlarged lymphatic glands may, however, be found associated with simple tumours when any local sources of irritation arise, and they may be absent for months, years, or altogether in certain examples of cancer, particularly of the atrophic variety in which the disease spreads slowly, and shows no sign of activity. In a case now under my observation of scirrhous cancer of fourteen years' standing, the lym- phatic glands are uninvolved, 17. Discharge from the nipple when free is more than suggestive of a duct cyst ; where the discharge is serous, of simple serous disease ; where blood-stained or blood, of cystic disease complicated with intracystic growth, either of a simple or cancerous nature. 18. A slight sanguineous discharge from the nipple in the absence of nipple trouble, is suggestive of glandular cancerous disease, since simple non-cystic benign tumours never give rise to a discharge from the nipple unless associated with some degenerative cystic disease of the gland. 19. A slow growing, almost painless, nodular elastic tumour of the breast, over which the skin is thinly stretched before it becomes infiltrated and later on ruptured, and which discharges a tenacious mucoid fluid; more or less blood-stained, is certainly a colloid. 326 CHAPTER XIX. ox MORBID CO]!^DITIONS OF THE NIPPLE. The sm'geon should in all affections of the breast be well alive to the fact that the nipple may be congenitally deficient, small, flattened out, or not prominent as it is normally. He should remember that a naturally well-formed nipple may have be- come deformed, or retracted from some inflammatory condition which occurred in early life, or followed a pregnancy which took place long before the complaint for which he may have been consulted appeared. He should know, moreover, that the nipple may have been destroyed by ulceration of a simple or malignant form, or that it may have sloughed off from some in- flammatory trouble. He should, likewise, have clearly in his miiid the fact that a nipple may have become flattened out or retracted from the growth of a simple benign tumour or cyst situated in the centre of the gland, and he should not jump to the too common conclusion when he finds a retracted nipple associated with a neoplasm, that the new growth is a cancer. A retracted nipple when associated with certain other morbid conditions is a valuable symj)tom of scirrhus, whereas by itself it has no significance. There can be little doubt that as a positive in- dication of cancerous disease, the importance of a retracted nipple has been considerably overrated ; and that, although the symptom may be common in infiltrating cancer of the breast, such a disease may exist without it. It may be present, moreover, in simple non-cancerous affections. A retracted nipple may be regarded as an accidental symptom in Ckap.xix.] Diseases of the Nipple. 327 the development of a tumour, and also as the pro- duct of mechanical causes ; its presence being deter- mined rather by the manner in which the gland is involved than by the nature of the disease. If any tumour, cystic or solid, simple or malignant, any abscess, chronic or acute, attack the centre of the mammary gland, a retracted nipple in all probability Avill be produced ; for as a disease so placed neces- sarily causes material separation of the gland ducts, their extremities, terminating in the nipple, will be drawn upon, and, as a consequence, a retracted nipple must follow. AYe thus find this symptom of frequent occurrence in the early stage of an infiltrating cancer of the origan, the nipple being always drawn towards the side of the gland which may be involved ; while at a later stage, when the infiltration Ls more com- plete, the nipple' may again project. In a central chronic abscess of the breast, in a case of cyst or of adeno-fibroma or sarcoma, tlie retracted nipple is equally common, and in the true cystic adenocele it may be also present. In the ordinary adeno-fibroma or sarcoma, whether cystic or otherwise, it is rarely met with, for the reason that this disease is not of the breast gland itself, but only situated in its neighbour- hood. In exceptional cases, however, such an association may co-exist. In one case in which I ob- served it, a blow or injuiy had preceded the de- velopment of the adenoid tumour, and it was open to a doubt whether the retracted nipple had not been brought about by some chronic inflammatory con- dition. It should always be remembered, moreover, that a contracted nipple may be a natural condition A discharge from the nipple should always attract attention. When the discharge is slight or of a bloody nature, it does not indicate any special affection, though it is well known that in cancerous affections a discharge from the nipple is not unfrequent, the fluid 328 Diseases of the Breast. [Chap. xix. Laving the appearance of blood-coloured serum, which is never profuse, and rarely amounts to more than a few drops. In the true cystic affection this symptom is of considerable value, for in the majority of the cases which have passed under my observation, iis well as in the recorded examples, this discharge from the nipple was a prominent feature, the fluid being generally of a mucoid nature, and more or less blood-stained ; and although at times it occurred spontaneously and with relief to the patient, at others it could readily be induced by some slight pressure upon the parts. In the ordinary solid forms of adeno-fihroinata or sar- comata, this symptom is seldom present. It exists therefore as a symptom in the true cystic disease of the breast structure, whether cancerous or sarcoma- tous ; and is consequently, as a means of diagnosis, of some value. " The fluids," wroteBirkett, "which sometimesooze from the nipple at the commencement or during the progress- of a new growth, may be rendered subservient to the formation of a correct diagnostication of the nature of the disease in the part. Sanious, offensive opaque discharges containing cells, identical with those forming growths of cancer, may be regarded as in- dicative that the induration which would probably accompany the exudation of such fluid arises from in- filtrating carcinoma ; whilst a bright yellow, clear, tenacious, serous fluid, drawing out into thread-like processes, and the flow of wliich is perhaps increased by compression on a circumscribed collection of fluid, would guide the surgeon to an accurate opinion that the tumour depended upon the presence of an adenoid growth, or a simple cyst." * Injaammation aiid laleeratiou of tlie uipples is a serious trouble, since it is too often tlie * Birkett : Holmes' "System of Surgery," vol. iii. p. 429. Third edition. ciiap. XIX.] Diseases of the N'ipple. 329 l)recursor of mammary abscess. It is more likely to occur in first than in later pregnancies, but if women become feeble at the second, third, or fourth pregnancy, this affection may appear, although they may have escaped the trouble on former occasions. At times the affection shows itself as an inflammation of the nipple and its areola, with all the local phenomena of inflammation or swelling, red- ness, heat, and pain. In a certain number of cases the inflammation will subside under treatment, and the parts recover their normal condition. In the majority of cases some local ulceration follows, and this may show itself either as a local "fissure," "chap," or "excoriation," or as a superficial or deep ulcer. In exceptional cases the nipple may 1)6 entirely destroyed. The ulcers are generally found between the rugse or about the base of the nipple. In the worst cases the areola is likewise involved. The ulcerated surfaces are always painful and generally bleed. When the process of suckling is attempted the pain becomes agonising, and the haemorrhage more abundant. That the pain should be severe under these circumstances can be readily understood. With these local symptoms there is usually much constitutional disturbance. It has been asserted that these ulcers are com- monly caused by some aphthous condition of the child's mouth ; I believe they may be so in some cases, but in the majority they result from some un- usual sensibility of the skin of the part, and at times from want of care. In first pregnancies the nipples should always be well looked to, and kejot scrupulously clean, and if tender they should be bathed with some mild spirit lotion, or eau-de-Cologne and water, and well protected from friction of the dress by cotton wool or some glass or guttapercha shield. These shields help to make the nipples more prominent, and 330 Diseases of the Breast. [Chap. xix. at the same time consequentlv prepare tliem for their fimctioru Where ulceration exists, soothing applications are the most valuable, such as Peruvian balsam, castor oil, or almond oil. At times glycerine is of use, whilst at others it causes pain. When sore nipples occur at the time of suckling, shields should be v.'crn. Great care should be observed to dry the nipples after the use of shields, and never to leave the shields in the child's mouth after the suck- ling has been completed. The application of the glycerine of tannic acid, Richardson's styptic colloid, tincture of catechu, a solution of nitrate of silver (gr. V to the ounce of water), or an ointment of extract of rhatany (gr. \\\] to 5ij of the oil of theobroma), are good applications. The summit of the nipple, whence the milk flows, should never be touched with the applica- tion. Whatever applications are used they should be washed off before the child suckles. In a few cases I have advised the use of a five per ceut. solution of cocain before suckling, with great advantage. When cracks exist, it is a good plan for the mother to draw out the nipple by means of the old-fashioned feeding bottle before giving it to the infant, the mother's nip- ple being put into the central opening, and her mouth drawing the artificial one. Another ready method is the application to the nipple of the mouth of a wide- necked empty bottle that has been heated by hot water, the nipple, as the bottle cools, being pressed into the bottle and rendered prominent in a painless way. All breast pumps are to be condemned. Eczema of the nipple and areola, or of the latter alone, is a form of dermatitis which must be recognised. It may appear as an eczema in other parts of the body, and get well by local treat- ment ; or persist, become chronic, and eventually take on the form of what Yelpeau described as " eczema Char. XIX.] Diseases of the Nitple. 331 i-iibriini," and pass into Paget's disease of the nipple, tlie ])recursor of cancer, to which attention has been ah'eady drawn. This eczema may attack single or married women, young or old ; the more chronic variety is generally met with in the latter. It is rarely confined to the areola, but spreads to surrounding parts ; it often attacks both breasts. It is best treated by alkaline soothing application, such as a lotion of the bicarbonate or borate of soda, five grains to the ounce, with some extract of opium, to get off the scabs, and then an ointment of zinc or lead, separate or combined, or one of soda bicarbonate ten grains to the ounce, or of boracic acid. In the acute stage, simple lead and opium lotion is the best. Alkalies with some vegetable bitter form the best internal medicine, but tonics and alteratives are often required. The diet must always be simple, and little or no stimulants are, as a rule, required. When the disease has spread to the end of the nipple, and reached the orifices of the ducts of the gland, it may creep into them, and it is possible that in this way epithelioma may arise ; but this question has already been discussed. Follicular abscet^s of the areola is by no means uncommon ; it may occur alone or in associa- tion with an eczematous or other form of dermatitis ; it is to be treated as any other follicular inflammation, and usually soon runs its course and gets well. Ellen D., aged 37, the mother of four children, the youngest being eight years old, came to me in June, 1865, with suppuration of many of the follicles of the areola of her right breast. The disease had existed for eleven weeks. By the use of lead and opium lotion and tonics, recovery took place. Sebaceous Imnours of the areola. — These occasionally occur, and may give trouble if not 332 Diseases of the Breast. [Chap. xix. recognised. I have the notes of three such cases that came under my care when out-patient surgeon at Guy's, and they all occurred in young women ; they may, however, be found in women of maturer age. The cases are as follows : On December 1, 1867, Mary Gr., aged 32, came under my care with a well-marked sebaceous tumour in the areola of her right breast. It had been coming for months. I turned it out of its bed as a whole by pressure through an incision, and the case did well. Pedunculated sebaceous tumour of the areola. — On June 13, 1863, Susan D., aged 42, applied to me at Guy's Hospital, for a tumour hanging from the areola of the left nipple. It was pedunculated, and the size of a small nut. It had existed for three and a half years. When removed it turned out to be of a sebaceous kind. Mary C., a married woman, aged 22, came to me on March 5, 1863, with a sebaceous tumour, the size of a nnt^ above and in contact with the nip]3le, which had been growing for five months. It had commenced during suckling. I removed the growth by turning it out of its bed. It was clearly sebaceous. Charlotte S., aged 24, tbe mother of one child, consulted me on May 30, 1867, for an ulcerating sebaceous tumour on the margin of the areola of the right breast, which she had observed ten weeks. I enucleated the tumour, and the patient rapidly recovered. These tumours may become the seat of cancer. I remember an example of epithelial cancer of the areola of a breast of a middle-aged woman, which followed a tumour which had existed for years, and broke down. I believed the case at the time to have been one of fungating sebaceous cyst ; the interior of the cyst on its being emptied having become the seat Chap. XIX. 1 Diseases oe the Nipple. 333 of epithelial cancer in tlie same way as is well known " wens " upon the head or sebaceous cysts on other parts of the body occasionally do. Cci'owtli!** upon flic nipple and areola.— Warty, papillary, pedunculated, tibrocellular, or other growths may be found upon the nipple, which will be recognised by their ordinary appearances. I have W>^. Fig. 13.— Pedunculated Papilloma of the Nipple. seen many such, and give the particulars of two of the cases, the notes of which I have preserved. These growths should ahvays be removed. In the Guy's museum there is a preparation (2,300^'*^) of a pedunculated papillomatous growth, the size of a nut, Avhich was attached to the nipple of a woman, aged 48 (Fig. 13). It had been growing for twenty- six years, and during that time she had had ten children, all of whom she had suckled. Mr. Howse removed it. Pedunculated fihro-cellidar groioih on the apex of the nipjyle the size of a nut. — This was met with in the person of Annie S., aged 27, a single woman, about to be married, who came to me in May, 1864. It 334 Diseases of the Breast. [Chap. xix. had been growing two years, and was clearly of the softer kind of fibro-cellular growths. I removed the growth with a pair of scissors, and a good result followed. Pedunculated growth the size of half a nipiole growing from the lower border of the areola of the nipjole. — SusaD D.,aged 42, came beforeme on June 18, 1863, with a pedunculated growth connected with the areola of her left breast, three-quarters of an inch long. It was firm to the touch, and apparently fibrous in texture. It had been gi^owing for four years. She would not have it removed. In the museum of the College of Surgeons (Prep. 4,819^) there is a specimen of a pedunculated papil- lary tumour, nearly one inch and a half in length, which is smooth, firm^ and lobulated. jMicroscopically the growth was composed of overgrown fibrous tissue ; but sections taken at its attachment show^ed an in- growiih of small well-defined epithelium, not like those of epithelioma. The growth was removed by Mr. J. Hutchinson from a woman aged 38. In the same museum there is likewise a preparation presented by myself of an extremely atrophied breast only two and a half inches in diameter, of which the nipple is enlarged by a growth of dense fibrous tissue, both within and beneath it, and is pyramidal in shape. The other parts of the gland are of firm fibrous tex- ture, but are less dense than the nipple. With the microscope, only fibrous tissue and a few compressed atrophied ducts, and no cancerous growth, could be found. It was removed from an elderly lady. Cliancre of the nipple is an aff'ection which must not be left out of mind when the surgeon is consulted for an ulcer of the part. I have seen several examples of the kind, with the most typical chancres, infecting and non-infecting. A chancre upon this tissue presents much the same local appearance Chap. XX.] Multiple Growth. 335 as one upon the external part of the male prepuce. It is to be treated in the same way. The subject is mentioned here in order that the student and practitioner may be reminded of the possibility of the nipple being the seat of primary syphilis, the mere recollection of which renders the accurate diagnosis of a case more probable. CHAPTER XX. ox THE PRESENCE OF MORE THAN ONE NEOPLASM IN THE SAME SUBJECT, AND ON THE SHRINKAGE OF TUMOURS. It is not common to find in the same subject more than one kind of neoplasm, or to meet with cases of cancer having apparently more than one centre. I have, however, the notes of a few such cases, in which the breast, with other parts, has been involved. I quote them simply as curiosities, and as material for future study, and not as texts for speculative opinions. The first case is a very remarkable one : Case 1. Rapidly growing sarcoma of right breast, associated with atrophic scirrhus of the left breast of twenty years^ growth, and lipoma of the side; re- currence of sarcoma, and repeated operations, in a lady, now 68 years of age. — Mrs. T., aged 64, a very healthy looking woman, consulted me in 1882 for an ovoid, smooth, semi-elastic tumour, the size of a cocoa- nut, which occupied the position of her right breast. She was the mother of three children, all of whom slie nursed with the left breast, but not with the right, as it was hard and gave no milk. The tumour had 336 Diseases of the Breast. [Chap. xx. been growing for about eight montlis, slowly at first, but rapidly for the last three months. The breast was lost in the tumour ; and the skin and nipple, though liealthy, were stretched ; there was no enlarge- ment of the axillary glands. The tumour was fleshy and elastic, with a smooth outline. It moved with the bi'east upon the parts beneath. I regarded it as a sarcoma. In the left, or opposite breast, was a typical atrophic carcinomatous tumour, which had existed for sixteen years. The breast was contracted up into a stony mass ; the skin over it was puckered, but not infiltrated, and was adherent to the breast gland ; the nipple had retracted deeply into the breast. The left axillary glands were not found to be enlarged. The carcinomatous tumour gave no trouble, nor was it the seat of pain. Over the left hip there was a lipoma, the size of a fist, of twenty-five years' growth. This was disre- garded by the patient. On Jan. 9th, 1883, I removed the tumour with the right breast. The tumour was succulent, and on section show^ed a homogeneous structure ; a glairy fluid exuded from its surface, which was of a pinkish- grey colour. Under the microscope the tumour was made up of spindle and round cells, wdth but little fibre tissue. The case did well after the operation, but a return in the neighbourhood of the scar soon took place, for w^hich another operation was demanded. This in its turn was followed by a speedy convalescence, and again by the return of the growth. Up to the present time, July, 1887, four and a half years after the first operation, sixteen operations have been performed, and the patient's general condition is excellent. Re- pair follows each operation in a most satisfactory way, and beyond the necessary trouble connected with an operation, the general health of the patient suff'ers in Chap. XX.] Multiple Tumours. 337 no way. Neither tlie carcinoma of the breast nor the lipoma has made any progress. The dates of the sixteen subsequent operations are as follows: July 19th, Oct. 24tli, 1883; April 2nd, July 2nd, Oct." 8th, 1884; Jan. 16th, June 20th, August 13th, Oct. 29th, 1885; Eeb. 10th, April 28th, July 17th, Oct. 9th, 1886; Feb. 9th, April 13th, July 6th, 1887. Sometimes one growth has been removed, at others several. Every growth has had a delicate capsule, and each one has been readily enucleated. Some have been in the fatty tissue of the part, others have been in muscle; some have been in the glands. The specimen removed on April 2nd, 1884, was examined by Dr. Goodhart, who reported the " gTowth is a mixed sarcoma, chiefly a spindle-cell sarcoma, but there are some myxoma-like cells in several places." Mr. Symonds examined the tumour removed on July 2nd, 1884, and reported as follows : "The tumour was oval, measuring l^in. by fin., perfectly smooth in outline, and covered by a thin capsule. No breast or other tissue was attached to it. It was soft and elastic, of a grey colour, and showed an almost uniformly homogeneous section. It could easily be broken down by pressure, but at two points was somewhat more resistant. The surface when scraped yielded a thin gelatinous fluid, containing cells of various shapes, the majority were oval, with several nuclei, and many were spindle-shaped. The nucleus of the latter closely resembled the former cell. There were also a few round cells. Microscopically the harder parts showed inter- lacing tracts of spindle-cells, cut in vaiious places, giving the alveolated appearance common to such tumours. The vessels were numerous, the arteries having well-defined walls, while the veins appeared as spaces in the tissue, and being in places collected in w— 25 33S Diseases of the Breast. LChap. xx. groups, gave a cavernous aspect to this part of the section. In the softer parts the vessels were more numerous but smaller, the cells also smaller and more of them round, the whole having the appearance of granulation tissue. The typical cell was a spindle, with a large oval granular nucleus. The spaces re- ferred to above as venous were of various shapes, and suggested, from their arrangement, that they com- municated. Their walls were very thin, and showed elongated nuclei in a amall amount of imperfect fibrous tissue, but. as stated above, appeared more as spaces in the growth. Though this is the common structui'e of veins in new growths, the arrangement in groups or plexuses seemed to call for special mention, as the spaces might be mistaken for cysts. Their resemblance to the singly placed apertures, and the absence of any epithelial lining, confirms the inter- pretation here given." Mr. Eve,- of the College of Surgeons, examined the tumour removed on Feb. 10, 1886, and reported that it consists entirely of round cells in mucous tissue. " Probably," he adds, " the original growth belonged to the class of tumours formerly known as recurrent fibroids. The elements get more elemental with each recurrence as a rule." In this matter Mr. Eve is doubtless correct. It is a point of great interest to find in a woman, now 68 years of age, a most active growing and re- curring sarcoma, side by side with an indolent atrophic carcinoma, and with her general health perfect. It is likewise worthy of note that in this case, as in cases 2 and 24, recorded in the chapter on cystic sarcoma, the disease attacked glands that had failed to secrete milk. Case 2. Carcinoma of the breast, one year ; Uj^o- tnata of groins thirty years. — Caroline B., aged 57, the mother of one child, came to me on Feb. 21, 1867, Chap. XX.] Multiple Tumours. 339 with a scirrhous infiltration of her right breast and adherent skin over the tumour which was fixed to the parts beneath. The axillary lymphatic glands were likewise enlarged. The disease had been dis- covered one year. Two large pendulous lipomata, the size of cocoanuts, also existed in the groins, which had been growing for thirty years. Case 3. Carcinoma associated with an adeno- fihroma of the right breast; amputation of breast. — Eliza C, a single woman, aged 49, came under my care in May, 1885, with a tumour in her right breast, which had been growing for about three years. When seen the lower and axillary lobes of the right breast were evidently infiltrated with some new material, and the swelling formed a tumour three inches in diameter. It was hard and nodular to the touch, and moved with the breast upon the parts beneath. The nipple was natural, skin dimpled ; the axillary glands were not felt to be enlarged. On June 6 the breast was removed, and on ex- ploring the axilla some lymphatic glands were found enlarged and taken away. The patient did well, and left the hospital in one month. On making a section of the tumour, one-third of the gland was the seat of a true scirrhus, and the gland tissue about it was the subject of cystic degener- ation. Between the cancerous tumour and the nipple, and upon the surface of the gland, there was a second tumour, the size of a nut, which was encapsuled, and on section presented a coarse lobulated surface, and to the eye and microscope yielded the appearance of an adeno-fibroma. In the Museum of the College of Surgeons a specimen of a like kind has been jDlaced by Mr. J. Hutchinson. Case 4. Carcinoma of the breast folloicing efithe- lioma of the nose. — Jane B., aged 63, a childless married woman, came under my care in 18G1, with epithelial 340 Diseases of the Breast. LChap. xx. cancer of one nostril. This I removed, and a good re- covery took place. Five years later, that is on June 25, 1866, when she was 68 years of age, she came to me with a hard infiltrating carcinoma of her right breast, associated with a puckering of the skin over the breast, w-hich had been coming for eight months. The dis- ease progressed very slowly ; one year later tuber- cles appeared in the skin over the breast, and the axillary glands became enlarged ; six months later the arm was oedematou&, and she died towards the end of 1868. Case 5. Carciiwma of the breast of twenty five years^ growth, followed by einthelial cancer of the nose. — Frances H., a widow, aged 72, with one child, came to me on July 1, 1865, with a marked example of atrophic carcinoma of her right breast of twenty years' standing, which had been ulcerating for seven years. In February, 1871, that is^ six years later, when she was 78 years of age, she came to me again with a marked epithelial cancer of one of her nostrils. The breast trouble, which had then existed for twenty- six years, had altered but little. Case 6. Infiltrating carcinoma of breast, and ulceration of the ni'pple ; preceded by discharge from nipple associated with canceroits stricture of the ceso- jjhagus. — Mrs. G., a thin feeble woman, aged 60, came under my care on February 25, 1885, with a central hard tumour infiltrating the whole of the left breast, and a raw red ulcer occupying the position of the areola and nipple, and enlarged axillary and lym- phatic glands. The nipple had entii^ely disappeared by ulceration. She was the mother of two children, the youngest being 25, both of whom she suckled without trouble. For eight or nine years previously she had had a watery discharge from the nipple, and nine months later the discharge was bloody. Two years ago the nipple became sore, and this soreness spread ; Chap. XX.] Multiple Tumours. 341 about this time a lump appeared in tlie centre of tlie breast. As the soreness of the nipple spread, the nip})le steadily disappeared, and the tumour of the breast increased. For five years she had had steadily increasing difficulty in deglutition, and for some months had only been able to take milk with sopped bread. The smallest size bougie can be passed through a stric- tured oesophagus. As no active treatment was possible, I did not see this patient again. Case 7. Lymph-adenoma of cervical glands, fol- lowed hy acute hravmy cancer of the breast, and subsidence of the sicellirig in the lytnj)hatic glands. — Sarah B., aged 49, a childless married woman, came under my care in 1875, with enormous enlargement of the lymphatic glands in both sides of her neck, and behind and beneath the jaw. The swellings were composed of tumours the size of eggs, which could be moved about beneath the skin. These glandular swellings had been gradually coming for fifteen years. The woman was feeble and leucsemic. Four years later this woman came to me again with a brawny carcinoma of her left breast, which had commenced four years before as a small lump, which grew slowly, and steadily involved the gland as a whole. When seen, the breast was generally infil- trated and hard. The skin covering it was adherent to the breast and felt like brawn ; it had, moreover, in different parts many distinct indurated cancerous tuber- cles. The lymphatic axillary glands were enlarged. Oddly enough, however, from the first appearance of her breast trouble, the cervical lymph-adenoma steadily subsided, so that when coming under obser- vation but very slight enlargement of the glands could be made out. 342 Diseases of the Breast. [Chap. xx. The woman had a red complexion and a watery eye, • but her urine was natural. Her powers were feeble, and I learned later on that she sank from what was supposed to be internal cancer. The association of these two diseases is very in- teresting, and the fact that the lymph-adenoma di- minished as the carcinoma increased is remarkable. On March 6, 1874, I was present when my col- league jNIr. Durham removed from the buttock of a woman, aged 65, an epithelial cancer the size of a florin, from whom Mr. Hilton had excised, twenty- three years pre^dously, the right breast for cancer, and the scar was then a good one. On the same day Dr. S. K. Fowle, of New York, who was visiting London, told me that in 1858 he saw the late Dr. Gross remove from the cicatrix of an ope- ration in the breast of an old woman a carcinomatous tumour, the size of a walnut, of one year's growth ; Sir A, Cooper having excised the woman's breast thirty years before for cancer. I would also here draw attention to the case of colloid tumour of the breast, published at page 201, in which the removal of a colloid growth in the breast was, eight years later, followed by a typical scirrhous carcinoma of the opposite breast. Case 8. Carcinoma of the left hreast ; excision ; return in the scar nine years later ; four years after re- moval of hreast, the apj^earance of a melanotic sarcoma in a mole situated in the left axilla; excision and no return ; uterine cancer eight years after the removal of the hreast; and carcinoma of the left femur, fracture of hone, and death nine years after removal of the hreast. — Mrs. K., aged 50, the mother of seven children, all of whom she had suckled without difficulty, the young- est being sixteen years of age, consulted me in May, 1876, with an infiltrating carcinoma of her left breast, which had been slowly growing for two years. The Chap. XX.] Shrinkage of Tumours. 3.43 nipple was retracted, and the skin about the nipple iiitilbrated. No axillary glands were enlarged. On May 3, 1876, the breast was removed, and a rapid recovery followed. The axilla was not ex- plored, as nothing could be felt through the thin integument. Four years after the operation in her breast, a mole, which had existed in her left axilla, on the side from which the carcinoma had been removed, became the seat of a melanotic sarcoma. After six months' growth, when it had attained the size of a nut, I took this away and no return took place. In 1884, eight years after the operation on her breast, the neck of the uterus became the seat of cancer ; the disease appeared as a nodule the size of a hazel-nut, and from this there was at times free bleeding. About this time the left arm became oedematous and painful. In December of 1884 she complained of pain and stiffness in the upper part of her left thigh, which soon became swollen, and before many weeks had passed it was evident that the upper part of the femur was enlarged. In June, 1885, some car- cinomatous tubercles appeared in the scar of the breast operation, and when getting into bed she felt some- thing give way in her thigh, and heard a crack. Dr. Curgenven, her medical man, saw her, and discovered a fracture at the seat of the" swelling, and there can be no doubt as to the swelling being a cancerous tumour. From this time she steadily sank, and died in August, 1885, nine years after the removal of a carcinoma of the breast, and five years after the excision of a melanotic sarcoma of the axilla. Case 9. Melanotic sarcoma originating in a mole situated in tlie right axilla, folloived in four years by an infiltrating carcinoma of the right breast. — Mary P., aged 40, a single healthy woman_, came to me in April, 344 Diseases of the Breast. LChap. xx. 1872, with an ulcerating melanotic sarcomatous growth, the size of an orange, which had originated two years previously in a mole in the right axilla. No enlarged lymphatic glands were to be felt. On April 25th I excised the growth, and a good re- covery followed. The patient remained well for nearly four years, when the breast of the same side became painful and enlarged, and six months later, when she came to me for advice, the breast was evi- dently the seat of. an infiltrating carcinoma. The scar of the operation for melanotic sarcoma was sound, and no signs of recurrence were present. In July, 1876, I removed her breast, which on section was clearly of a carcinomatous nature, and a good recovery ensued. In 1884, eight years after the I'emoval of her breast, and twelve years after the excision of the sarcoma, this patient was known to be quite well. Siu'iukag-e of tmnoiu'S.— Adeno-sarcomatous and fibromatous tumours, in very exceptional occasions, diminish in size by time. I have certainly seen two examples of the kind and am disposed to think that the diminution in the size of the growth is to be ex- plained by the absorption of such fluid as might have filled the growth or its capsule, rather than to any true shrinking of the neoplasm itself. Explain the matter how we will, the fact must, however, be recognised. The cases are as follows : Case 10. Adenomata in the hreast of a sudding woman, vjJiicJi diminished in size subsequently. — Eliza F., aged 22, a married woman, pregnant four months, came to me on ]\Iarch 15th, 1868, with an adenoma- tous tumour, the size of half a cocoanut, in the axillary border of her left breast, and a second the size of an orange in the sternal border of the same gland. The two had been growiug steadily for two years. During the progress of the pregnancy both Chap. XXI.] NyEVI OF BrEAST. ')^.\^ these tumours grew rapidly, and becauie at last twice the size they were. On Sept. 30th she was confined, and suckled with her right, or unaffected breast, for three months. The tumours in the left still grew. After weaning they, however, steadily diminished, so that on Jan. 3rd, 1870, that is, twelve months later, they had returned to the size described when seen in March, 1868. It should be added that this patient's single sister, when 21 years of age, came to me in June, 1870, with great enlargement of her left breast, from supposed hypertrophy. The gland was twice the size of the right breast. Case 11. Adenoma of the breast of eighteen years* groivth diminished hy time. — JMargaret K., aged 41, a single woman, came under my care on July 3rd, 1873, with a tumour in her left breast of eighteen years' standing, which was the size of an egg, soft, lobulated, and movable in and with the breast. It was quite painless. Eight years previously the tumour had been more than twice its present size. It had grown steadily for two years, when growth stopped and changed into shrinkage. CHAPTER XXI. TSMVl AND VASCULAR TUMOURS OF THE BREAST LIPOMATA AND CHONDROMATA OF BREAST. ISTiEVi are found in the skin covering the breast, in the same way as they are found in other parts of the body. In rare cases they may be found upon the nipple. I saw an example of this many years ago in a female child, who had a red, raised, florid n^vus, the size of a shilling, situated upon the breast 34^ I^ISEASES OF THE BrEAST. [Chap. XXI. and half the nipple. I destroyed it by means of the galvanic cauteiy, after two or three applications. Conrad Langenbeck has recorded cases of nsevi which have extended fi'om the skin to the breast beneath. Such cases in infants must be difficult to diagnose, since the breast as a gland is but rudi- mentary, and even when the nsevus involves the deeper tissues, it may be a question as to how far the breast may be involved. That the breast may be the seat of true nevoid disease there is no doubt, although such cases must be rare. I cannot find any examples recorded, beyond the one I have briefly alluded to in my work on the practice of surgery. In that case the breast, with the skin over it, was one vascular half globe. It was spongy to the hand, and could be emptied by pressure and easily refilled. The nipple was apparently re- tracted, but this condition was brought about by the elevation of the parts about it. The notes of the case as taken at that time are as follows : Ncevus invoicing the whole of the breast. — MaryE-., fifteen weeks old, was brought to me at Guy's Hospital on Oct. 14th, 1869, with a nsevus involving the whole of the breast gland and skin over it ; the nipple was re- tracted. The tumour measured two inches in diameter, and was like half a globe ] it was sjDongy to the feel and prominent. Large veins converged toward its surface and through the skin. At the margin of the gland the purple substance of the nsevoid structure was visible. The whole swelling could easily be reduced by pressure, and on the removal of which the swelling returned. Ko treatment was adopted. I^lponiata of tlie breast. — That lipomatous tumours may be found in the integument that covers the breast, that is, in the paramammary tissue, the experience of most surgeons will prove, although it is not so clear that they are met with within the Chap. XXI.] LlPOMATA. 347 gland structure or behind it. Gross says, " I am not aware of a single case of circumscribed lipoma occur- ring in the gland itself," and if he means by this a fatty tumour unconnected with the surrounding fatty tissue he is probablf/ right, and his experience most certainly coincides with my own. Sir A. Cooper in 1805 removed the breast of a woman which measured in circumference thirty-one inches, with a large lipomatous tumour, which was subsequently found to be situated behind the gland, and to have wei^died 14 lbs. 10 oz. He also removed from a woman who had a breast of great size, by a single incision, masses of fatty tissue from between the different portions of the gland which was itself healthy. " The lobes of fat which are interspersed between the different portions of tlie mammary gland, and which serve naturally to augment the size of the bosom, having become enlarged and formed a swelling, which, prior to the incision being made, seemed to involve the whole of the breast ; but when the operation was performed, the different lobes of adeps which formed the tumour could be drawn away from the gland itself." In the Guy's" Hospital Museum (Prep. 2300^0) there is preserved " a large adipose tumour, which measured 23 inches in cii-cu inference, and was removed after death from the breast of a married but sterile old woman, aged 87. When 30 years of age she observed the tumour in the upper part of the right breast, and this she showed to Sir A. Cooper on Jan. 9th, 1806. She remembered the date, because it was the day on which Lord Nelson was buried. The growth slowly enlarged, but not during the last few years. It was thought to have been an adenocele, but when a section was made it was found to consist of fat, with a piece of bone in the centre." Fig. 1 on Plate VII. was taken from this patient during life. 34^ D/S-EASES OF THE BrEAST. [Chap, XXI. A lipomatous tumour may, however, be developed in the tissue covering the breast or elsewhere. The following is an example of the affection : Lipoma the size of half an orange over the breast ; excision ; cure. — Annie B., aged 50, came under my care on Sept. 5th, 1883. She had had four children, the youngest being eleven years old. Five years ago she noticed a lump in the upper part of her left breast, which has steadily increased. When seen the lump was the size of half an orange, and measured three by two and a half inches. It was placed over the clavicular lobes of the left breast, and was movable over the gland. It was clearly lobulated and apparently fatty. On Sept. 7th I excised it and found it to be a pure lipoma. The case did well Cliondroinata. — These gi^owths are rarely met with in the breast. Sir A. Cooper gives one case, with a drawing, in his work on the breast ; he removed it from a healthy wouian, aged 32, and it was of four- teen years' growth. The pain in it was very severe, and the tumour was excessively hard. He removed the growth, and the larger portion of it had the appearance of that cartilage which supplies the place of bone in young subjects. The remaining portion was ossific. Fig. 2 on Plate YIII. illustrates the case. Professors J. Mtiller, Hindfieisch, and Billroth, record other cases in which nodules of cartilage were found in the breast. In the Guy's Museum, Prep. 2316-50, there is a tumour which was taken from the breast of a middle-aged woman. It was examined by Dr. Wilks, who pronounced it to be fibro-carti- laginous. In vol, xxxiii. of the Pathological Society's Trans- actions of London (p. 306), Mr. Bowlby reports a case of chondro-sarcoma of the breast, of one year's growth, taken from a woman, aged 42. The breast with the tumour, which was encapsuled, was removed. Chap. XXI. I ChONDROMATA. 349 but a return took place which proved fatal within six months of the operation. Cruveilhier has also described a case in vol. iii. of his " Anatomie-Pathologique," but Mr. Bowlby throws some doubt about its true nature. Upon the whole, although it must be accepted as a fact that the disease may occur in the breast, it is certainly very rare; It may occur as an innocent growth or in association with a malignant one. On May 18th, 1886, Mr. W. H. Battle showed the members of the London Pathological Society a specimen of osteo-chondro-sarcoma of the breast, Avhich is very rare. It was taken from the right breast of a widow, aged 73, who had had five children. The tumour commenced as a hard lump, to the inner side of the nipple, six years before. The growth was painless, and the patient's general health unaffected. It grew slowly until, within a year of its removal, it had attained the size of a large orange; it consisted of two portions, an inner, very hard and rounded, about the size of a walnut, which the patient had noticed for a long time ; and an outer, a more recent development, more elastic, of the size of a large Q^g. The nipple was much retracted. The skin was ad- herent, red, and tense at the inner part. One small freely movable gland was detected in the axilla. The growth consisted of a larger portion composed of a soft, friable, extremely vascular material, in which there had been numerous haemorrhages ; and of a smaller very hard portion which resembled bone, and could not be cut with a knife. Microscopic examination of the tumour showed it to consist, in the softer parts, of round and spindle cells ; and in the harder, of cartilage which had in parts become ossified, the section showing well- marked Haversian canals. 350 CHAPTER XXII. TUMOURS OF THE MALE BREAST. The male breast is liable to tbe same affections as the female, but in a far lesser degree ; the male gland at no period of its life being called upon to show any functional activity. It may, in infancy, be as frequently the seat of inflammation as the female gland, and in a former chapter it has been shown to be liable about puberty to a marked growth, and to a spurious functional activity, which may lead up to inflammation. It may also, as a result of injury, be the seat of abscess. Fibromata, sarcomata, and adenomata have been met with in the gland, and carcinomatous tumours are not rare. Thus Mr. W. R. Williams reports that out of about 280 examples of adenomata of the breast, con- secutively noticed in London hospitals, one was in a male ; of 68 examples of sarcomata of the breast, two were in males ; and of 1433 cases of cancer of the breast, fourteen were in males ; or roughly speaking, that one case of benign tumour of the breast is met with in the male to 1 16 in the female ; and one case of carcinoma in the male to 102 in the female; car- cinoma in the female being at least a hundred times as common. These averages are doubtless quite reliable, since they have been calculated from the combined experi- ence of four large London hospitals^ during ten, twelve, and seventeen years. They difier from smaller statistics published by Sir J. Paget, who believes that two cases of scirrhus of the breast occur in men to 98 in women ; by Gross, who has seen two examples in males to 100 in females; by Billroth^ who gives seven Chap. XXI i.] Tumours of Male Breast. 351 cases in males out of 252 cases ; or taking all these cases together, in the proportion of one to forty- two. Wagstaffe gives, in vol, xxvii. of tlie Pathological Society's Transactions (p. 246), a table of sixty-one cases of cancer of the breast in the male, collected from all sources, from which we learn that in only six of the whole number the disease appeared under the age of 40 ; in twenty it api)eared between the ages of 40 and 60 ; in seven between the ages of 60 and 70 ; and in seven in subjects over 70 years of age. The disease has evidently a tendency to occur in old rather than in middle-aged men. The diagnoses of these cases of neoplasm in the male, as well as their treatment, is to be determined by the same symptoms, signs, and conditions, as those of the female. INDEX Abnormal condition of breast. 6 Abscess of breast at puberty, 21 , cases of, 23 , Cbronic, 45 dviring lactation, 24 , Effect of, on secretion, 19 in infants, 20 , cases of, 21 in males, 53, 54 in pregnancy, 24 , cases of, 31 , Intraglandular, 29 simulating cancer, cases of, 46 , Submammary, 34 , , cases of, 35 , Superficial. 29 Acetic acid, Injection of, in carci- noma, 216,234 Adeno-tibromata, 81 associated with, carci- noma, 339 , Cystic, 254 , Degeneration of, 97 , Diagnosis of, 103 • , Illustrative cases of, 108 in men, 102 , Macroscopical appear- ances of, 90 , Multiplicity of, 100 , Prognosis of, 104 , Eapidity of growth, of, 99 , Statistics of, 102 , Subjects of, 101 . , Symptoms of, 97 , Treatment of, 105 Adenomata, 81 • , Macroscopical appearances of, 90 , Symptoms of, 97 Adeno-sarcomata, 115 associated, with carci- noma, 335 X— 25 Adeno-sarcomata, Clinical features of, 119 , Cystic, 254 — , Diagnosis of, 121 , Illustrative cases of, 124 , Treatment of, 123 , Varieties of, 116 Agalactia, 59 Alternation of benign tumours, 94, 108 Amputation of breast, 229 . , Dressing after, 230 Anatomy of breast, 1 Annandale, Mr. , case of cancer in mother and daughter, 153 Areola of nipple, 5 , Eczema of, 163, 330 , Follicular abscess of, 331 , Sebaceous tumours of, 331 Arsenic as a local caustic, 233 Ashwell. Dr., case of adeno-fibro- ma, 112 Atrophic cai'cinoma, 141 , Operations in, 211 Atrophy of breast, 17 Axillary glands, Removal of, 231 , Resolution of, in carci- noma, 181 lumps, 12 Banks, Mr., on complete removal of breast, 204, 223 Beck, Marcus, on early explora- tory incision in cancer, 207 Benign tumours, 81 Billroth on scrofulous inflamma- tion, 65 Birkett, Mr, J., case of hydatid, 320 , on adenoma with secretion, 84 , on alternation of benign tu- mours, 94 354 Diseases of the Breast. Bii-kett, Mr. J., on nipple dis- cliarge, 328 , statistics of milk abscess, 25 Brawny carcinoma, 145, 185 _ , lUnstrative cases of, 188 , Operations in, 212 Breast, Anatomy of, 1 , Atrophy of, 17 , Development of, 6 , Evolutionary cbsnges of, 22 , Examination of, 55 , Functions of, 58 , Hypertrophy of, 13 , Irritable, 55 , On the association of morbid growths in, 335 , Tumours of, 73 , , Benign, 81 , , Cancerous, 132 , , Cystic, 216 , , Diagnosis of, 322 , , Excision of, 229 , , Hydatid, 316 , , Sarcomatous, 115 Bruce, Dr. Mitcliell, on super- numerary glands, 6 Cachexia in cancerous tumours, 1.55 Cancer of breast associated with adeno-fibroma, 339 associated with cancer of nose, a39 associated with cancer of oesophagus, 3^0 associated with lymph- adenoma, 341 associated with sarcoma, 335—342 cells, 138 juice, 133 , see Carcinoma, 132 Cancerous cachexia, 155 Carcinoma, 132 , Age in relation to, 148 and pregnancy, 153, 210 , appearance on section, 138 ■ , Atrophic variety of, 141, 211 , brawny variety, 145, 185, 2J2 , Breast involved in, 150 , Cachexia in, 155 , Cases of, unfit for operation, 218 , Causes of, 159 , , Summary of, 171 , Clinical features of, 171 , coUoid variety, 134, 146, 199 , common variety, 144 Carcinoma, cystic variety, 146 , , Diagnosis of, 306 , Degenerations of, 194 , Diagnosis of, 171 , Discharge from nipple in, 178 , Duration of life in, after operation, 152 , , without operation, 153 , Early local symptoms of, 172 , Eczema of nipj)le in, 163 , Excision of breast for, 229 , Hard, 144 , ileredity in, 157 , how it spreads, 136 , Illustrative cases of, 235 , Injury as cause of, 159 , Local nature of, 135 . Lvmphatic infection in, 136, 180 , Macroscopical features of, 140 of both breasts, 213 of male breast, 147 , Eecurreuce of, 137, 217 , Retraction of nipple in, 176 , Scirrhous variety of, 144 , Sex in relation to, 147 , Signs and symptoms of, 137, 171 , Social condition and fecun- dity in, 149 , soft variety, 165, 198 , Treatment of, 202 , Tuberculation of sliin in, 184 , Tuberous, 145 , Tubular, 293 , Ulceration in, 194 , Varieties of, 140 Cases illustrative of abscess -of breast, 31 , acute abscess in girls, 23 , adeno-fibroma, 108 , adenoma secreting milk, 84 , adeno-sarcoma, 124. , association of carcinoma and adeno-fibroma, 339 , association of carcinoma and sarcoma, 835 , atrophic carcinoma, 142 , brawny carcinoma, 183 , carcinoma of breast after eczema, 167 , after injury, 162, 239 , ■ after mastitis, 239 , and epithelioma of nose, 339 Index. 355 Cases, carcinoma of breast and epithelium;! of oesopliagus, 340 , and lymph - adenoma, 341 , and melanosis, 342 , in both br.asts, 213 , in jiretrnancy, l.')4, 210 - — ■, treated by acetic acid, 2 It) , with skin tuberculatiou, , chronic aisles , 43 , clinical symptoms and tr< atment of carcinom i, 235 , colloid carcinoma, 201 , cysti ^ aden '-fibrom i, 270 , adeno^arcoma, 277 , carcinoma, 291 , — — involution changes, 251 , duct cyst«, 257 - — , galiictocele, 314 , hydatid disease, 316 , inflammation in male, 54 . lipomata, cliondromata, 346 — 348 , melanotic sarcoma, 131, 3i2 , multiple carcinomatous tu- mours, 245 , nsevus of breast, 316 , nip]ile discharge in carci- noma, 178 , recurrent carcinoma, 220 , resolution of lymphatic glands in carcinoma, 181, 242 , sero-cystic disease, 265 , shrinkage of tumoiirs, 344 , specific mastitis, 72 ,tumours of nipple and areola, 331 Caustics in carcinoma, 232 Champney, Dr., on mammary functions of skin, 12 Chancre of nipple, 334 Chondromata, 34S Chronic abscess, 45 , cases of, 46 Classification of tumours, 80 Co-existence of carcinomatous and sarcomatous tumours, 335 Colloid carcinom 1, 134, 143 , Clinical features of, 199 Congestion, Lactic, 27 Connective tissue tumours, 115 Cooper, Sir Astley, on sci'ufulous inflammation, 62 Creighton, Dr. C, on Irjast de- velopmt-nt, 4 , on inflammation, 26 , on tumour formatio.i, 73 Cuirass variety of carcinoma, 1P4 Ci'stic tumours, 246 , adenoma, 238 , , Diatrnosis of. 305 , carcinoma, 14), 21 d , , Diagnosis of, 303 , degeneration of gland, 218 , Piaarnosis of, 303 , Formation of, 2.54 — , Prognosis of, 307 , sarcoma, 268 , , Diagnosis of, 305 , sero-cystic disease, 265 , simple cysts, 2'4 , Treatment of, 309 Cvsts, Duct, 25t — , Hydatid, 316 , Involution, 248 , Lacteal, 310 , Proliferous, 268 , Suppuration of, 253 Darsvin on heredity, 158 Development of brea-t, 6 Diagnosis of tumours, 322 of adenomatous tumours, 103, 305 of carcinomatous tumoiu-s, 137, 306 of cystic tuinours, 3 \3 of sarcomatous tumours, 121, 305 Dimplmg of skin in cancer, 174 Duct cysts, 254 Ducts of breast, 5 DuLring, Dr., on Paget's disease, 166 Duncan, Dr. Matthevrs, on galac- torrhoea, 61 Durant, Dr. G., on scrofulous breast, 65 Duration of life in c ncer, 151 with operation, 152, 219 without operation, 153, 219 Early local symptoms of cancer,172 operations in cancer, 232 Eczema of uippl ■, 16 >, 330 preceding carcinoma, 163 Encnpsuled tumours, 81 Epithelial elements, Arranse- ment of, in adenoma and carci- noma. 93 Esmarchs caustic, 233 Examination of breast for tu- mour, 55 356 Diseases of the Breast. Excision of breast for cancer, 228 Exploratory operations in doubt- ful tumours, 207 Fibromata, 81 Follicular abscess of areola, 331 Functional aberrations as cause of tumours, 73 disorders of breast, 55 , Treatment of, 57 Galactocele, 310 Ga,lactorrboBa, 60 Gland, Supernumerary, 7 Gould, Pearce, on complete exci- sion of breast, 204 Gross, Dr. S. W., on cancer, 198 , on operations in cancer, 219 , on growth of sarcomata, 120 , on heredity in cancer, 157 Growth, of benign tumours, 99 Hard carcinoma. See Scirrhous carcinoma, 144 Heat, Increase of, in cancer, 185 Heredity in cancer, 157 Howse, Mr. G., case of papilloma of nipple, 333 Hydatid tumoui's, 316 Hypertrophy of breast, 13 Infection in carcinoma, Local, 135 , Lymphatic, 136, 180 , Vascular, 137 Infiltrating tumours, 132 Infiltration of shin in cancer, 175 Inflammation of breast, 19 at puberty, 21, 37 in infants, 29, 36 in lactation, ^ in male, 53 in pregnancy, 24, 38 , Scroftdous, 62 , Symptoms of, 26 , Syphilitic, 69 ^ , Treatment of, 36 of cysts, 258 Injury as a cause of carcinoma, 159 Involution cysts, 248 Irritable breast, 55 in boys, 53 , Treatment of, 57 Lacteal cysts, 310 , Diagnosis of, 312 , Treatment of, 313 Leichtenstern on supernumerary glands, 7 Lipoma of breast, 346 Lncal irritation, cause of cancer, 160 Locality, Influence of, in cancer, 170 Lymphatic glands, Resolution of, in cancer, 181 , Eemoval of, 231 infection in adenoma, 99 in cancer, 136, 180 Male breast, Inflammation of^ 53 , Tumours of, 351 , Sarcomata in, 121 Malignant tumours, 132 Mammae, Supernumerary, 7 Mammary glandular tumour, 81 Mastitis, 19 , Relation of, to new growths, 161 , Scrofulous, 62 , Syphilitic, 69 Medullary carcinoma, 145 , Chnical features of, 198 saxcoma, 116 Melanotic sarcoma, 131 Menstruation, Influence of, in carcinoma, IcO Mental anxiety, cause of cancer, 169 Metastatic deposits in cancer, 224 MHk fistulEe, 44 , Secretion of, 3 Moore, Charles, on operation of breast excision, 203 Morris, Henry, on treatment of cancer by caustics, 233 , statistics of metastatic de- posits, 224 Multiple tumours. Benign, 100 myxomatous degeneration, 97 Nsevi of breast, 345 Nerves of breast, 5 Nipple, AnatOD y of, 5 Chancre o., 334 Discharge from, 327 - — ■ in adenoma, 328 in carcinoma, 178 in cystic disease, 3 8 Diseases of, 326 Eczema of, 163, 330 Growths from, 333 Retraction of, 326 in adenoma, 177 in cancer, 176 Supernumerary, 7 Ulceration of, 328 Index. 357 Non-eucapsnled tumours, 132 Non-infiltratiug tumours, 81 (Edema of breast, 24 in carcinoma, 186 Operations on breast, Complete, iu cancer, 227 , Early, in cancer, 20o . ' Exploratory, in doubt- ful tumours, 207 for atropliic carcinoma, _I for benign growths, 105 for brawny cancer, 212 for cancer of both breasts, 213 for cancerous ulcers, 208 for cancer when asso- ciated with pregnancy, 210 , comparison of ope- rations, 226 . for carcinomatous growths, 202 !_ , for local recm-rence after operation, 222 lor recui-rent cancerous growths, 217 — ^ , Inadequate, 202 , Mortality after, for can- cer, 226 , Statistics of, for cancer, Paget, Sir J., on duration of life in cancer, 153 , statistics of carcinoma, 149 Paget' s disease of nipple, 163 Palliative treatment of carcinoma, 234 Pregnant women. Abscess of breast in, 24 , Cancer in, 153 , , Operations in, 210 Proliferous mammary cysts, 268 Puckering of skin iu cancer, 174 Puerperal mastitis, 24 , relation to carcinoma, 159, 171 Eecurrence of adenoma, 101, 104 . of adeno-sarcoma, 121 of carcinoma, 137 after operation, 222 , Treatment of, 217 . of cystic sarcoma, 308 Ketraction of nipple after inflam- mation, 21, 33 Ketraction of nipple after inflam- mation in benign tumours, 98, 177 in carcinoma, 177 Sarcomata, adeno-, 115 , Cystic, 2B8 , Diagnosis of. 121 , Growth of, 115 , Melanotic, 131 , , and carcinoma, 342 of male breast, 121 , Treatment of, 123 Scirrhous carcinoma, 144 , Diagnosis of. 172 , Treatment of, 202 Scrofulous inflammation of breast, 62 , Varieties of, 65 Sebaceous tumours of areoja, 331 Sero-cystic disease, 254, 265 Sex, in relation to carcinoma, 147 Shipman, Mr. G., a case of hy- pertrophy, 16 Slirinkage of turaovu's, 344 Sinuses after abscess, 35 , Treatment of, 4i Skin, Dimpling of, in cancer, 174 ■ , Infiltration of, in cancer, 175, 184 , Puckering of, in cancer, 174 , Stretching of, in benign tu- mours, 99, 305 , Tuberculation of, in cancer, 184 Social condition, Kelation of, to carcinoma, 149 Soft carcinoma, 145, 198 Spontaneous suppuration of cysts, 258 Statistics of abnormalities of breast, 6 of inflammation, 25 of adeuo-fibromata, 102 • of adeno-sarcomata, 121 of carcinoma, 147 , age when discovered, 151 and eczema of nipple, 167 as infecting disease, 198 as influenced by locality, 170 , dm-ation of hfe with operation, 152 , duration of life with- out operation, 153, 219 , Leredity in, 157 , influence of age in, 148 , influence of sex iu, 147 33S Diseases of the Breast. statistics of carcinoma, metastatic deposits in, 224 , mortality of operations in, 226, i:27, 229 , social condition on, 149 Sabmammarv abscess, 34 , Treatment of, 43 inflammation, 28 Sapemumeiary gland and nipple, 7 , Causes of, 7 Suppuration of breast, 20 of cysts in breast, 258 Suspensory ligaments of breast, 2 Symonris, Mr. Charters, report on case of iuvolution cysts, 251 , report on case of cystic ad eno- sarcoma, 286 , rep'^rt on case of duct ade- noma, 273 . report on case of tubular cai*- cinoma, 2y2 Syphilitic mastitis, 69 Targett, Mr., report on case of Paget's disease, 168 Thin, Dr., on Paget's disease of nipple, 164 Thomas, Dr. Gaillard, on excision of tumours, 107 Treatment of abscess, 42 Treatment of benign tumours, 105 of carcinomatous tumours, 202 of cystic tumours, 309 of inflammation, 3t Tuberculation of skin in cancer, 184 Taherous carcinoma, 145 Tubular carcinoma, 293 Tarn ours of breast, Classification of, 80 ■ -, General remarks on, 73 , Benign, 81 , Cancerous, 132 , Cartilaginous, 343 , Cvstic, 246 , Fattv, 346 , Hydatid, 316 , Irritable, 55 , IVIelanotic, 131 , Shrinkage of, 3 14 Vascular infection of cancer, 137 tumour, 345 Telpeau, M , on results of opera- tion in cancer, 219 , on scrofulous swelling, 63 , on syphilitic mastitis, 69 Williams, Dr. "W. 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Authoritative Work on Health by Eminent Physicians and Surgeons. The Book of Health. A Systematic Treatise for the Professional and General Reader upon the Science and the Preservation of Health . 21s, Roxburgh 23s, CONTENTS. By W. S. SAVORY, F.R.S Introductory, By Sir RISDON BENNETT, M.D., F.R.S. — Food and its Use in Health. By T. LAUDER BRUNTON, M.D., F.R.S.— The Influence of Stimulants and Narcotics on Health. BySiRj.CRICHTON-BROWNE, LL.D., M.D.— Education and THE Nervous System. By JAMES CANTLIE, F.R.C.S. — The Influence of Exer- cise on Health. By FREDERICK TREVES, F.R.C.S.— The Influence of Dress on Health. By J. E. POLLOCK, M.D.— The Influence OF our Surround- ings ON Health. By J. RUSSELL REYNOLDS, M.D., F.R.S.— The Influence OF Travelling on Health. By SHIRLEY MURPHY. M.R.C.S. — Health at Home. By W. B. CHEADLE, M.D.— Health in Infancy and Childhood. By CLEMENT DUKES, M.D.- Health at School. By HENRY POWER, F.R.C.S. — The Eye and Sight. By G. P. FIELD, M.R.C.S.-The Ear and Hearing. ByJ. S. BRISTOWE, M.D., F.R.S. — The Throat and Voice. By CHARLES S. TOMES, F.R.S. — The Teeth. By MALCOLM MORRIS.— The Skin and Hair. By SIR JOSEPH FAYRER, K.C.S.L, F.R.S., and J. EWART, M.D.-Health in India. By HERMANN WEBER, M.D. —Climate and Health Re- sorts. Edited by MALCOLM MORRIS. "A volume which deserves hig^h praise throughout, and which will find its uses in every household."— 7"iwany, Limited, Ludgate Hill, London. "An EncyclopaBcUa of Sanitation."— Spectator. Oicr Ho7nes, and How to Make them Healthy, With numerous Practical Illustrations, Edited by Shirley FORSTER Murphy, late Medical Officer of Health to the Parish of St. Pancras ; Hon. Secretary to the Epidemiological Society, and to the Society of Medical Officers of Health. 960 pages. Royal 8vo, cloth . . . IBs. Roxburgh ..... 18s. CONTENTS. Health in the Home. By w. B. RICHARDSON, M.D., LL.D., F R S Architecture. By P. GORDON SMITH, F.R.I. B.A., and KEITH DOWNES YOUNG, A.R.I.B.A. Internal Decoration. By ROBERT w. EDIS, F.S.A., and MALCOLM MORRIS, F.R.C.S. Ed. Lighting. By R. BRUDENELL CARTER, F.R.C.S. Warming and Ventilation. By DOUGLAS GALTON, C.B., D.C.L., F.R.S. House Drainage. By Y\^ILLIAM EASSIE, C.E., F.L.S., F.G.S. Defective Sanitary Appliances and Arrangements. By PROF. W. H. CORFIELD, M.A., M.D. Water. By PROF. F. S. B. FRANCOIS DE CHAUMONT, M.D., F.R.S. ; ROGERS FIELD, B.A., M.I.C.E. ; and J. WALLACE PEGGS, C.E. Disposal of Refuse by Dry Methods. By THE EDITOR. The Nursery. By WILLIAM SQUIRE, M.D., F.R.C.P. House Cleaning. By PHYLLIS BROWNE. Sickness in the House. By THE EDITOR. Legal Responsibilities. By THOS. ECCLESTON GIBB. &c. &c. " A large amount of useful information concerning all the rights, duties, and privileges of a householder, as well as about the best means of rendering the home picturesque, comfortable, and, above all, wholesome." — Times. Seventh and Cheap Edition. Price is. 6d. ; cloth, 2s. A Handbook of NttrsUig For the Home and for the Hospital. By Catherine J. Wood, Lady Superintendent of the Hospital for Sick Children^ Great Or ??iond Street. Cassell & Company's COMPLETE CATALOGUE, containing particulars of several Hundred Vohimes, i?icluding Bibles a?id Religious Works, Illustrated and Fine- A7-t Vohimes, Childre7?'s Books, Dictionaj'ies, Ediicational Works, History, Natural History, Houselwld and Domestic Treatises, Scie?tce, Travels, ^c, together with a Sy?iopsis of their mimerozis Illustrated Serial Publications, sent post free on application. CASSELL S: COMPANY, Limited, Ludgnte Hill, Londoji ; Paris, NeTt) York, & Melbourne. /6 COLT IMRT A T TNTTVPl? 9TTV T TRP A P TPg ; DUE DATE the IA4I i 4AAi FTP P 1994^ JmN 1 * 1 h;\ ^ *3; j4 iPRi^m n MAY a 9:^ kki «16?tl?' V '^ '. ■■ ^ , ' Vi _^: J V P / 201-6503 Printed In USA ?U03Ban^ que mmn^sdCf,^ jo aSaflo^ ■<^;-t;^^g^y| ^^^: - :^*-' ' / ^ y;