CHAPTER XLIV

.

THE BREAST.

ANOMALIES OF THE BREAST.

_Amastia_, or complete absence of one or both breasts, is a rare defect. _Polymastia_, or the occurrence of _supernumerary breasts_, is more frequent.[51] These may be found on any portion of the thorax or abdomen, and may constitute masses of trifling size or may bear considerable resemblance to the normal breast. A supernumerary breast has even been found upon the thigh. The condition is to be regarded as atavistic, and a return to the polymastia of animals, which produce a litter at one birth. Similarly absence of the nipple, _amazia_, is occasionally seen, or more frequently _polymazia_, the occurrence of more than one nipple, either upon the normal breast or in some abnormal position. Some of these lesions are so small as to escape observation, or to be considered moles unless carefully noted and recognized when found.

[51] History records interesting examples of the importance attached to these conditions. Thus the beautiful Anne Boleyn fell under the displeasure of King Henry because of a supernumerary breast, and it is said that the mother of the Roman Emperor Alexander Severus was given the name of Julia Mammæ because of a similar abnormality.

Ordinarily supernumerary breasts are met near the middle line and below the normal mammary gland. A more common condition is one of defect of the nipple, which fails to assume its normal prominence and remains ill-developed, so as not to be seized by the infant in the act of attempting to nurse. Nevertheless with the physiological activity which occurs in the breast at the time of pregnancy these ill-developed nipples usually expand sufficiently to fulfil their function, even though imperfectly.

_Hemorrhages_ from the breast sometimes take place idiopathically, at others as vicarious efforts at menstruation. There is a peculiar sympathy between the pelvic organs of women and the mammary glands, and the latter evince this in more than one way, becoming sometimes extremely tender or swollen at the menstrual period, or at other times peculiarly sensitive or even neuralgic, while at times congestion will proceed to the point of hemorrhage. These conditions do not require particular attention, but are not to be confused with a bloody discharge that may occur later in life, in connection with certain forms of malignant disease occurring in the interior of the breast.

[Illustration: FIG. 524

Idiopathic hypertrophy of breasts in a girl of sixteen. (Bebee.)]

There exist the widest differences in development of the breasts in different individuals. The term “breast” is used intentionally, since the difference is not so much in the actual glandular development as in the surrounding connective tissue and fat. Thus a plump breast may contain very little more secreting structure than one apparently ill-developed. Nowhere outside the uterus save in the breast do such compensatory changes take place under the stimulus of pregnancy. In fact, a mammary gland in preparation for lactation is a physiological adenoma. At conclusion of lactation there is absorption and atrophy from disuse, usually not to the original degree, although in some instances the fatty tissue disappears irregularly and leaves the breasts in quite different shape from their originals. In this way the breasts may become exceedingly pendulous, so much so as to lead to pain and soreness from traction, and to call for their support.

_Idiopathic hypertrophy_ of one or both breasts is a rare deformity, occurring usually in the young, sometimes in girls, involving them to an indefinite degree, but in some producing enormous overgrowth, with corresponding deformity. For such hypertrophy no known cause has been assigned. Fig. 524 illustrates an instance of this character in a young girl, occurring under the observation of my colleague, Dr. Bebee.

INJURIES TO THE BREAST.

These consist largely of _contusions_ to which, from their positions, the breasts are peculiarly exposed, and these may be followed by hemorrhage, by extensive ecchymosis, or by any of the consequences of infection. They may also be followed by more or less permanent _induration_. The fact that in the course of time certain contusions of the breast are followed by development of cancer is incontestable, although the relation which may exist between the accident and the neoplasm has not yet been made clear. The breasts are also subject to the same possibilities of injury as other parts of the thorax, which has been considered in the previous chapter. The _nipples_ are more often injured by efforts of the nursing infant, or by the friction of ill-fitting stays or rough clothing, than in any other way. These injuries, at first of a minor character, are not infrequently followed by serious results, erysipelas, septic infection, or tuberculosis being conveyed through trifling abrasions thus inflicted.

The nipple of a nursing woman once excoriated, or its surface broken, is kept constantly liable to maceration and surface infection. In this way a trifling lesion may result in a linear ulcer known as a _fissure_ (“cracked nipple”), or in a more extensive involvement. These fissured nipples are very erethistic, and great pain is caused by each attempt at nursing. On this, account the mother postpones the act as long as possible, and until her breast has become overdistended, the result being injury to the breast itself, with a greater possibility of infection and of subsequent abscess formation.

The slightest _excoriation of the nipple_, under any circumstances, should lead to the adoption of every precaution for its cleansing and protection. Both before and after nursing it should be carefully washed, while, after removal of the child from the breast, it should be carefully dried and dusted with dry boric acid or a similar antiseptic. Any abrasion which fails to heal should be treated with silver nitrate. More pronounced abrasions and ulcers should be cocainized, then cauterized, and afterward treated as above. Finally in extreme cases it may be necessary to discontinue nursing and allow the breast to dry. If this policy be adopted it should be applied to both breasts, for such is the sympathy between them that the use of one gland seems to stimulate the other. The local use of such preparations as belladonna ointment, etc., is to be avoided. Pressure, rest, and the care above described afford more relief.

_Paget’s disease of the nipple_ implies an eczematous condition, first described by Paget as a precursor of many cancers. It is a more or less chronic affection, involves the nipple and the areola, is quite intractable to treatment, gives more or less discomfort, and is to be dreaded when noted. It seems to sustain about the same relation to later cancerous involvement as does leukoplakia in the mouth and on the tongue.

There is no reason why any person may not have an attack of eczema about the nipple, but cases in which the condition is persistent and obstinate, and especially in which the underlying tissues gradually become infiltrated or indurated, should be viewed with suspicion, and should be treated by eradication of the area involved, even though this may require extirpation of the nipple or of the entire breast. When the condition is developed no ordinary treatment will suffice, although a fair trial might be given to the cathode rays.

MASTITIS.

A true inflammation of the mammary gland may occur at one of three periods: (1) At _birth_, when the tiny breasts of the newborn infant secrete a milk-like fluid, become more or less congested and tender, and when they are unintelligently treated by massage or interference of any kind; (2) at _puberty_, when a perfectly natural turgescence and congestion occur, which, however, rarely proceed to suppuration unless infected or unless violence or some indiscreet treatment have been received; (3) during _pregnancy and lactation_, this being the time when mastitis is most common.

Considering that the nipple affords a number of open paths, from an area which it is difficult to keep clean, extending into the depths of inflammable tissue, it is strange that infection through the milk ducts does not occur in most cases. Such a path of infection affords the explanation for at least a large proportion of mammary abscesses. Again the presence of excoriations, abrasions of any kind, and especially of deep fissures which are not easily cleansed, will account for infection through the lymphatics. In these two ways nearly all cases of mastitis and of mammary abscess are to be explained, and both these accidents are likely to occur during pregnancy and lactation.

The consequence of such infection is _mastitis_, which begins with painful induration and local indications of inflammation, but which may under suitable treatment undergo resolution. This failing, the infectious process proceeds to suppuration, and the consequence is a superficial, deep, or retromammary _abscess_, all but the last named often in multiple form. The lobular construction of the breast permits the independent occurrence of distinctive suppuration, occurring synchronously at several different points, and hence it may be that a breast is riddled with abscesses, which form successively or almost simultaneously.

There is a _superficial form_, which occurs usually near the nipple, and in which the deeper structure of the breast is scarcely involved. This comes usually through infection of some surface lesion. Simple incision is usually sufficient, and the local lesion is thus quickly terminated. _Deep or intramammary abscess_, single or multiple, is always painful, sometimes distressing and occasionally an extremely serious condition. Occurring in a breast already well developed and fatty, abscesses may form at such depth as to be recognized with difficulty. The surgeon infers their existence rather than discovers it. This is unfortunate, for the longer the delay the greater the local disturbance, with a tendency to burrowing, and the worse are the consequences for the patient. It is, therefore, far safer to early note the minor signs of deep suppuration and to freely incise, than it is to wait for pus to come toward the surface and give its ordinary surface indications. The amount of induration, sometimes dense and brawny, which such conditions will produce within the breast, the size which the latter may assume, and the consequent suffering to the patient from neglected conditions of this kind, need to be seen to be fully appreciated.

_Retromammary abscess_ may be the result of conditions not primary to the breast itself. Thus the writer has seen spontaneous perforation of the thoracic wall in a case of empyema, with escape of pus into the loose cellular tissue behind the breast, and the consequent protrusion forward of the latter until it presented as an enormous tumor. Treatment in such cases would mean not alone evacuation of the retromammary collection, but emptying the pleural cavity of its accumulated fluid.

An infected breast will produce not only the ordinary local indications, but will be characterized by extreme tenderness, with enlargement of the lymph nodes in the axilla and later abscess formation in this location. In proportion to the amount of pus thus imprisoned, and the virulence of the infecting organisms, constitutional symptoms may be mild or extreme.

Nowhere is there greater need for release of an imprisoned amount of pus than under these circumstances, although the incisions necessary for the purpose may be sometimes multiple and deep. Every incision made for evacuation of a mammary abscess should be placed _radially_--_i. e._, in a line radiating from the nipple--in order that lobules may be incised along their course, and that neither they nor vessels be cut across transversely. There is also need for complete drainage, and several tubes may be used for this purpose, being passed completely across or beneath the breast.

=Chronic Mastitis.=--Chronic mastitis may be the termination of a

## partially resolved acute process, or of injury, or of apparently

unknown causes, being in these instances of apparently spontaneous origin. Pathologically it comprises induration, with more or less infiltration of the interacinous and interlobular tissue, and with some infiltration of the other structures of the breast, by which fixation, retraction of the nipple, or condensation of the surrounding structures and adhesion of the overlying skin are produced. The result may be to produce either an enlargement or diminution in size of the breast. One or both glands may be involved. It is a disease usually of late adult life.

Breasts thus affected are often tender and painful, especially during menstruation, and upon palpation are found to be irregular in shape, more or less nodulated, extremely firm in some cases and places, and perhaps so infiltrated as to strongly simulate cancer. The changes which are thus produced are slow, and it is important to note that the lymphatics are usually not enlarged, and that after attaining a certain degree the diseased condition becomes stationary. The general health usually does not suffer beyond a certain point; at least even in the more chronic cases there is no characteristic cachexia. While the condition is more frequent in women who have nursed it may be met in those who have never borne children nor have been married.

_Suitable examination_ of all these cases can only be made with the upper portion of the patient stripped, the body in the horizontal position, and both breasts compared and examined, first with the flat hand in order that differences of shape, size, mobility, and fixation may be determined. Subsequently the patient should be raised to the sitting position, the surgeon standing behind to examine each breast with one hand and simultaneously, in order that differences may be more accurately noted. Any tumor present will be more easily discovered with the flat hand than with the finger-tip, while chronic induration will not give the sensation given by neoplasms. The axillæ should also be carefully examined, as well as the supraclavicular regions, for evidences of lymphatic involvement. When the entire breast is involved diagnosis is less difficult than when one or more lobules alone are concerned. These constitute the painful nodular conditions to which so many names have been given by different writers.

Significant features in their differentiation from cancer are the disproportionate pain and tenderness, their diffuse leathery hardness, and the fact that both breasts are usually similarly involved, though perhaps not to the same extent. Cancer is, on the other hand, somewhat dense and confined to one breast, and affords a sensation of infiltration of the surrounding tissues, with the peculiar “saddle-skin” retraction or adhesion of the overhang skin and nipple. Moreover, the growth is more rapid and localized, and the lymphatics are involved in nearly every instance. Some of these cases are so obscure that diagnosis previous to operation is impossible, while innocent lesions may gradually merge into malignant, and no one can say when the transition begins or has begun.

=Treatment.=--The milder forms of chronic mastitis gradually improve under the influence of local applications such as the ichthyol-mercurial ointment, to which menthol may be added for its soothing effect. Pendulous or painful breasts should be supported as much as possible. Otherwise these cases are best let alone--_i. e._, they should not be rubbed or massaged. There is usually a constitutional condition which is closely related, and in nearly every instance there is more or less failure of elimination. These features should be studied and treated as they are identified. Finally there are some intractable forms of innocently indurated breast which give so much trouble that it is best to remove them as though they were cancerous.

NEURALGIA OF THE BREAST; MASTODYNIA.

Many women suffer from annoying and painful affections of the breast for which no sufficient excuse is found, while others who have small fibrous nodules or innocent lobular tumors will suffer an amount of pain which is disproportionate, and in instances of either type we are prone to point to the neurotic or hysterical features of the case and to say that it must be, at least to a certain extent, neurotic. Inasmuch as these cases usually occur in young and otherwise neurotic women, often of the more impressionable type, it is generally proper to consider them as to some extent hysterical, while in others there are pelvic accompaniments which may perhaps account for neuralgic breasts, because of the well-known intimate relations between the pelvic organs and these glands. In some cases, again, are found actual small tumors, single or multiple, but of innocent character. In other cases there are hypersensitive areas of entire breasts, to a degree where the patient cannot stand the slightest handling. These cases are hyperesthetic, even if not hysterical, and some are unsatisfactory to treat. The pains are more or less periodical, and often radiate down the arm or the side of the thorax; this may be explained through the intercostohumeral and other nerve connections.

=Treatment.=--The treatment of mastodynia should include constitutional, local, and moral measures, but of these the local are the least important. The excision of painful nodules is often disappointing, the remaining scars becoming even more sensitive than the original lesions. Women who under these circumstances have insisted upon the removal of an entire breast have still suffered from intercostal neuralgia or other remaining painful conditions, so that their ultimate condition has not been much improved. Each case should be studied upon its merits, and while one may be benefited by some pelvic operation, or another by Turkish baths and improvement of elimination, others are best let alone, or given a minimum of drugs with a maximum of general and sexual hygiene.

TUBERCULOSIS OF THE BREAST.

I cannot agree with writers like Fowler, who claim that tuberculosis of the mammary gland is extremely rare. I think it not infrequent. In the breast may be noted the presence of lesions, either separate or coalescing, and gummas as such, or breaking down into caseous masses or into cold abscesses. In connection with the local lesions there may be more or less involvement, even to ulceration, of the overlying skin, with the formation of lupoid ulcers, while the axillary lymphatics will be nearly always involved. In some instances the disease may have gone on to suppuration and burrowing of pus, with its discharge, and the existence of tuberculous sinuses; or in others may be seen results of a secondary infection of the remains of multiple mammary abscess. The condition is most often met with in the young and fair, but may be seen in elderly women. Around the distinctly tuberculous lesions there may be considerable tissue sclerosis. The actual proportion of cases is about one of this condition to fifty of cancer. Lesions are more frequent in the outer quadrant of the breast than the inner, and they occasionally produce retraction of the nipple or adhesion of the skin, above described, before its distinct involvement.

In any of these circumstances secondary purulent infection may occur, and an acute phlegmonous process may seriously complicate the previous chronic condition.

=Treatment.=--There is but one satisfactory method of dealing with tuberculous disease of the breast--_i. e._, its extirpation. The entire breast, or so much of it as may be distinctly involved, should be extirpated as though it were cancerous, while the axilla should be opened and its contents cleared out, if it appear in the slightest degree involved. Moreover, every other tuberculous lesion in the neighborhood should be eradicated, either with the knife, the scissors, or the sharp spoon. After such radical treatment results are usually satisfactory.

## ACTINOMYCOSIS; SYPHILIS OF THE BREAST.

_Actinomycosis_ is not common in this location; nevertheless tissue conditions are such that it would furnish accessible and diagnosticable features which would be distinctive, at least until some secondary infection had occurred.

_Syphilis appears_ in this location in many of its protean manifestations. _Chancres about the nipples_ and on the surface of the breast are not uncommon, the disease being often conveyed from syphilitic infants through cracked nipples, while many other methods of contamination have been reported. Near the nipple the chancre may not have those characteristics which usually distinguish it upon the genitals, but may appear rather as an indurated, intractable ulcer, with firm base, accompanied by distinct involvement of the axillary and supraclavicular nodes, and unless early recognized and promptly treated as such will so endure until the occurrence of the first significant secondary eruption, whose appearance should dispel doubt and lead to radical treatment.

There is difficulty, sometimes, in distinguishing between tuberculous and syphilitic skin lesions upon the breast, especially near the nipple. When other methods fail the therapeutic test will nearly always clear up the difficulty. All truly syphilitic lesions here, as well as elsewhere, yield promptly to well-directed treatment.

TUMORS OF THE BREAST.

The mammary gland is a frequent site for tumors, although neoplasms of embryonic origin are not as frequent here as might perhaps be expected. Nearly one-fifth of all tumors occurring in the body will be found in this location, while the larger proportion of breast tumors are malignant.

_Cysts_ abound in this locality, occurring in one or both breasts, and singly or in exceedingly multiple form, the latter being small and containing but a few drops of fluid. Their cystic contents are colorless and of a serous consistency, sometimes thick and mucous, occasionally discolored, and in rare instances almost like unchanged milk. In the latter case the condition is known as _galactocele_.

In an organ so thoroughly provided with ducts it is easy to understand how _retention cysts_ may readily occur from plugging of some duct and the accumulation of secretion behind it. Should it occur at a time when milk is forming galactocele may be readily explained. At other times it is in every respect an abnormal development. This occlusion of the ducts may be the result of disease or of injury, and is not always complete, for it often happens that from a distended duct more or less accumulated material may be expressed by gentle pressure. In this case it will be found thick and loaded with the epithelial cells which line the passages. These retention cysts are spoken of as serous, mucous, or sanguinolent (blood cysts), according to their contents, while the lacteal contain material more or less resembling butter. _True galactocele_ seems to be rare. While the original contents are milky it is claimed that through changes taking place in the neighborhood induration and proliferation in the surrounding membrane may result, or that mammary tissue may soften and break down into pulpy detritus.

_Cystic tumors_ in the breast may be of innocent character, or may assume all degrees of malignancy. A cyst whose lining membrane is smooth, without reduplications or irregularities, may be regarded as innocent, while the complete extirpation of its walls will be all that is required. This may be made more complete after injecting it and staining it with methyl blue, or filling it with melted paraffin in order to occupy the place of the fluid, which should have been drawn off. On the other hand, every cyst whose interior is roughened, _or presents the slightest papillomatous appearance_, or which is unduly _adherent_, or has about it any mark of _infiltration_, calls not only for its own eradication, but for practically the complete removal of the breast.

The _signs of cystic tumor_ in the breast are essentially those of any other neoplasm, except that it is frequently possible to recognize its cystic character by fluctuation. A cyst ordinarily presents as a distinct tumor, and when innocent is circumscribed and non-adherent, lacking the clinical evidences of malignancy. Pain is an uncertain feature. Most cysts develop slowly, but a cyst developing suddenly after parturition or during lactation, without previous local inflammatory changes, is probably a galactocele. The small multiple form of cyst, with which one or both breasts may be studded, is frequently confused with chronic mastitis, from which it is difficult to separate it. The escape of sebaceous material or of milky fluid from the nipple, or the possibility of making it appear by gentle pressure, will probably afford the best indication. If along with this possibility the nipple be found ulcerated, or if the extruded fluid be bloody, complete extirpation of the breast would be the only suitable measure.

=Treatment.=--The general treatment of cyst has been indicated. It is a question simply of how extensively the eradication should be made. The advice of the older text-books is misleading, and it is the studies of very recent years which have shown how early the lining membrane of apparently innocent cysts may undergo malignant changes, by which the breast is soon compromised and which necessitate its entire removal.[52]

[52] It will be a safe rule to follow if it be assumed that every cyst whose contents are bloody, unless this can be traced to recent accident, and especially every cyst whose interior is papillomatous, is on the border-land of malignancy, if not malignant in character. All such tumors then should be extirpated. If they occur in the breast a complete operation, as for cancer, should be done.

Of the _benign_ tumors _lipomas_ in the substance of the gland are rare, while they may frequently develop in its fatty surroundings. _Adenoma_ and _fibroma_, with their various combinations, are the most common of the innocent tumors, and they constitute single or multiple nodules, located in the substance of the gland, or in evident communication with it, constituting masses of well-marked density, slow growth, nearly always mobile and non-adherent to the skin, causing neither retraction of the nipple nor lymphatic involvement, and being frequently accompanied by a very disproportionate amount of pain and tenderness, some of them being, in fact, exquisitely sensitive. While these growths are rare previous to puberty they are frequently met in girls and young women, and, occurring in these neurotic subjects, they cause considerable mental as well as physical trouble. In these patients there may be found coincident pelvic disorder. The removal of these sensitive masses, which seems to be plainly indicated, is often disappointing, as the remaining scar may retain the original hypersensitiveness, and patients often suffer as much as before the operation.

The enlargement of the breast, which normally prepares it for lactation, is to be regarded as the development of a normal or _physiological adenoma_. Anything which simulates this under other conditions is abnormal, and any overdevelopment of true mammary gland tissue, when localized and circumscribed, should be referred to as _adenoma_. In such tumors cystic changes often occur, as well a later transformation into _adenocarcinoma_, something always to be dreaded. These changes are more likely to take place during lactation, at which time the blood supply to the breast is more free. The development, then, of _an adenoma in the breast of a nursing woman_ should be regarded with suspicion, and unless benign it should be regarded as demanding removal of the entire organ. These tumors also are non-adherent and lack the ordinary signs of malignancy.

=Cancer of the Breast.=--Cancer occurs in the breast more often than anywhere else, and _carcinoma_ constitutes about 85 per cent. of these malignant tumors, the balance being mostly sarcomas, the remaining small number being made up of endotheliomas and the other rare forms. The most common type of carcinoma is the so-called _scirrhus_, in which there is a large amount of dense stroma, and which forms a strong contrast with the rare forms of rapidly growing, true soft cancer--_i. e._, the _encephaloid_ or _medullary_ as they used to be called--in which the cancer cells proliferate with greater rapidity and in which there is a small amount of stroma, so that in consequence the tumor itself is soft or almost gelatinous.

_Sarcoma_ of the breast may assume either of its well-known types, and is a tumor seen in the earlier rather than in the later years of life. It sometimes grows rapidly and attains large size, seeming to approach the surface more rapidly and readily than ordinary forms of carcinoma. In consequence it may be mistaken for abscess. As a rule, however, the skin is not so likely to be adherent to the tumor as in carcinoma, and the lymph nodes are not so early involved, while in a cut section of the tumor the fat is not so disposed as in carcinoma, where it may be seen in layers, while in the former case it has been transformed into malignant tissue.

The two principal forms of _carcinoma_ are the _acinous_ and the _tubular_, in the former the cells being packed into the alveoli and surrounded with a firm and adventitious stroma, while in the latter the primary development seems to be within the milk ducts, which being first involved cause a more multiple minute invasion and a less distended tumor formation.

The _general indications of cancer in the breast_ are as follows:

The presence of _tumor_, sometimes of regular and definite outline, sometimes diffuse and not easily outlined.

_Fixation of this tumor_ in the surrounding tissues in such a way that it cannot be moved without disturbing them.

_Fixation of the general area_, either to the skin above or to the pectoral fascia below, or both. This gives to the part an immobility in contrast with normal conditions.

_Retraction of the nipple_, when the growth is large or located near it. This is a feature perhaps not noticeable in the primary stages when it is so important to recognize the disease if present.

_Retraction of the overlying skin_, at points if not over a considerable area, giving it a peculiar “saddle-skin” or “pig-skin” appearance. This indication of itself is always suspicious and one which should be noted if present.

In addition to the local evidences in the breast the _involvement of the nodes in the axilla_ and of the lymph vessels leading up toward it. These should be carefully studied, the patient’s arm being held loosely away from the body, and somewhat to the front, in order to relax the pectoral muscle. In fleshy subjects it may not be possible to discover them even if present. The supraclavicular region should also be examined, and enlargements may be felt here or along the cervical chain.

In addition to the above features others which are more indicative, because they point to advanced disease, are the appearance in the skin or just beneath it of shot-like nodules, more or less red, or of any mass which causes the skin to protrude and to have an unnatural appearance, usually one of lividity or threatening ulceration. _Pain is an uncertain and variable feature_, upon which little stress should be laid. The laity have incorrect notions about the constancy and significance of pain, and many a woman has deluded herself into the notion that she had no cancer because her tumor was not painful. _Pain is sometimes pronounced_ and severe, even radiating down the arm; _at other times it is absent_ until almost the terminal stage.

_Any tumor in the breast which presents any one of the above characteristics is to be regarded as at least suspicious, while the occurrence of two or more of the above features should stamp it as malignant, and consequently condemn it. This is equally true of the cancers which rarely appear in the male breast._

Cancer is supposed to be a disease of _middle and usually of advanced life_. _This, again, is an error._ To be sure, carcinoma is rare below the age of thirty, and yet one sees it not infrequently in women much younger than that. One of the saddest cases I have ever known was one of carcinoma of both breasts in a young mother of twenty-two, advanced to hopeless condition because her physician had held that it could not be cancer at her age, and because she had coincided with his belief, since she had not suffered pain.

The _course of a cancer in the breast_ depends on several factors. There is a rapidly growing type which tends to kill within a few months, this occurring usually in younger patients. On the other hand there is a slowly growing type which may last over a period of years. This is the so-called _atrophic cancer_, and its slow growth is due to the perfection of the protection afforded around the cancerous masses by the density of the stroma. Occurring in a fatty breast it leads to a diminution of its total mass, even though the cancerous features themselves be advancing, and this makes it sometimes hard to convince patients that a breast which is actually diminishing in size is becoming more and more seriously involved. _Cancer tends ever to advance, and sometimes_, as it were, _by leaps_, the method of invasion being usually one of steady progress and infection of the adjoining tissues; while metastases are to be expected as the case goes on, and occur sometimes in unexpected forms. Thus in cancer of the breast there is a well-known metastatic invasion of the bones, even of the extremities, with the consequent liability to so-called _spontaneous fracture_. In cases of the latter the former condition should always be suspected. There is a possibility always of invasion of the sternum and the ribs by continuity. It has been shown that invasion of the pectoral muscle, and even of the firm pectoral fascia, was a common result, and this demonstration has led to the adoption of the more recent radical methods of removing both of these structures along with the involved breast. In rare instances both sarcoma and carcinoma assume the _miliary type_, and evince it by a miliary invasion of the skin of the thorax which becomes gradually infiltrated, softened, and perhaps finally ulcerated, the involved skin thus having the aspect of a corset of diseased tissue, and being spoken of as “jacket cancer” or “_cancer en cuirasse_.” Such a condition may before the patient’s death involve the entire circumference of the thorax. Any of these miliary expressions of malignancy stamp a case with a hopeless aspect. General miliary carcinosis is also known to occur.

Nearly all cancers grow faster in the young. Other things being equal, there is a somewhat better prognosis for the condition in elderly people, and this applies equally to prospect of recurrence after removal.

In regard to the curability of cancer the reader is again referred to an earlier chapter on the general subject, but doubtless _there is a time when if the growth were recognized and thoroughly removed it would not recur_ and the patient might be cured. This time is, unfortunately, too often past when the case comes under the observation of one competent to deal with it. This is due partly to fear and ignorance on the part of the patient, and unfortunately too often to failure on the part of some practitioner to appreciate the significance of the early manifestations, _i. e._, to a failure in early diagnosis.

_Cancer also occasionally occurs in the male breast_, and I have record of a number of fatal instances of this kind. It is, however, quite rare. It is usually of the scirrhus type, but may be the result of epithelioma commencing about the nipple and spreading. It cannot assume marked size without becoming thoroughly distinctive, and probably ulcerating, and there should be no difficulty in diagnosis. It demands the same radical operation as cancer in the female (Fig. 525).

=Treatment.=--In regard to the method of treatment there is but one which needs to be seriously considered, _all others being fallacious and irrational. It is by operative removal alone that every hopeful case should be treated at the earliest possible date._ Patients may dread the knife and some men may fear to use it. Nevertheless the above statement holds true. Even then cure is not obtained unless the knife be used thoroughly. Treatment by plasters is barbarous and unscientific, as well as uncertain and absolutely unsurgical. None of the popular remedies is of the slightest value. Treatment by the Röntgen rays should be reserved for the hopeless cases or for _postoperative protection_. Eradication is, therefore, the only scientific surgical relief.

_Any growing tumor in the breast of a woman which cannot be clearly recognized as perfectly innocent demands operative removal_, and the operation itself should be made thorough if success is to be attained. In the presence, then, of lymphatic involvement, of any adhesion or infiltration of the overlying skin, or of the surrounding textures, or of retraction of a nipple, or of fixation of the breast upon its base, operation should be advised without any reference to the question of pain. Equally important is it to decide _when not to operate_. When the condition is disseminated, when the presence of cancer in any other part of the body can be demonstrated, when the lymphatics of the neck are notably involved, when the arm is already swollen from obstruction to the return circulation, when the skin presents numerous miliary nodules, or when from disturbance of the heart or of respiration--_i. e._, chronic cough--it might appear that there is involvement of the bronchial nodes, with consequent pneumogastric irritation, then it may be held that the case is so far advanced that it is useless to subject the patient to the risk entailed by operation. There are exceptions, however, even to this statement; such as an evidently hopeless case that has reached the stage of ulceration, in which discharge is offensive or hemorrhage recurring, when operation may be done for temporary and with humane purposes.

[Illustration: FIG. 525

Cancer of male breast. (Buffalo Clinic.)]

[Illustration: FIG. 526

Recurrent carcinoma eight months after incomplete operation in a woman seventy-five years of age, showing the extensive nodular, ulcerating surface surrounded by cancerous masses under the skin. The edema of the right arm from the circulatory obstruction occasioned by metastatic growths about the axillary vessels is well shown. (Parker.)]

_Recurrence_ is to a large extent inseparably connected with the matter of both _early and thorough removal_. Only when this can be practised should any hope of radical cure be offered. While the results attained by modern methods are very encouraging, they nowise contradict this statement. The discreet operator will, therefore, be guarded in giving a favorable prognosis or making promises. Fig. 526 illustrates many of the sad features pertaining to recurrence.

OPERATIONS UPON THE BREAST.

Every precaution having been taken the operator should decide whether the operation is to be enucleation of the tumor or complete excision of the breast, with dissection of the axilla. An evidently innocent tumor of small size may be removed, either through a straight incision, which should be placed radially, or by raising a flap with an ovoid incision, by which more perfect dissection is permitted. Small nodules and superficial growths may be removed under cocaine anesthesia. The first essential is to leave behind nothing of the mass which it is desired to remove; the second is exact hemostasis, and the third is the closure of the wound. It is possible to remove portions of the gland itself, as well as to enucleate tumors from within its substance. V-shaped incisions may be coapted with sutures, by which the size of the gland is reduced, but its general proportions maintained. Tumors situated posteriorly may be removed by making an incision beneath the breast, around its border, raising it from the thorax, and returning it to place after the necessary excision. It is advisable to provide a small drain for these cases, as in the more or less loose tissues of the breast blood is likely to accumulate, and by distending the wound to interfere with its repair.

_Operations for cancer of the breast_ are performed more radically than a few years ago. This is due to a more thorough knowledge of the pathology of the disease, and to the better appreciation of the value of thorough extirpation of all affected tissues, especially if this can be done _early rather than late_. Therefore the modern operation includes not only the removal of the breast and of the axillary nodes, but of the pectoral fascia and muscle, the fatty tissue in the neighborhood, and everything in which the disease may lurk.

The essential feature, then, of every case is the _removal of all tissue which may be involved_. It is therefore necessary to remove the skin covering the mamma, as well as the structures above mentioned. This is done by elliptical or ovoid incisions, the amount thus included being sufficient to take in every particle of skin which shows the slightest possibility of infection--_i. e._, every nodule or dimple which may be in any way connected with the primary disease. Inasmuch as only in cases seen early is it at all safe to be less radical than just mentioned the pectoral fascia and muscle should be removed. For these purposes large and long incisions are necessary, extending from the anterior border of the axilla down toward the costochondral junction, while the lower part of the opening is divided and the incision made elliptical, in order that the breast, with its coverings, may be completely removed. The upper end should follow the lower border of the pectoral tendon, or at least be placed near it, extending as far as the insertion of this tendon, since that portion belonging to the muscle excised should be divided at its insertion and removed with the rest of the mass. The incisions then are usually carried down first to the deep fascia, and then through this, in such a way that the underlying muscle may be lifted from the thorax and detached therefrom. The result is that there is dissected from the chest wall a total mass of gland, fat, fascia, and muscle, which is continuous upward and outward toward the axilla, from which the final dissection is made. Then, commencing on the outer side of the axilla, so much of the pectoral tendon is divided as may be necessary; close beneath it will be found the axillary vein, and this is next to be freed from its cellular and fatty surroundings. The dissection is now carried toward the deeper part of the axilla, vessels being secured before division, and the entire contents of the axilla being carefully removed in one continuous mass. This requires careful and sometimes tedious dissection, which is made much easier by exact hemostasis. If the greater part of the great pectoral muscle be removed, complete exposure of the axilla is easier. When this is not sufficient, because in the uppermost portion of the axillary cone may be felt enlarged lymph nodes, at the level of or beneath the clavicle, then the lesser pectoral should be divided at its middle, and its ends held apart, this affording a still better exposure of the axillary depths. By this measure the vessels and plexuses may be easily followed up to the level of the emergence of the former from the thorax, especially if the arm be held upward and forward, much depending upon the position in which the assistant thus holds it.

Everything which is actually involved should be sacrificed. This might even apply to the axillary vein, which may be doubly ligated and exsected. It will occasionally happen that it is cut or torn in some deep dissection. In this event, before resorting to final double ligation, an effort should be made to suture the opening with fine silk sutures passed with a round needle, which may be successfully done, or to secure a small tear within the jaws of a curved hemostat, may then be left within the dressings for forty-eight hours or longer; by this time a clot will have formed which will permit its detachment. While much work may thus be done upon the axillary vein the writer nevertheless has the feeling that when a case is advanced to such a degree as to demand this it is scarcely worth while, because recurrence is practically sure to follow. Nevertheless in the interest of general thoroughness, if the work has been begun, it is usually well to finish it as completely as possible.

[Illustration: FIG. 527

Diagram showing skin-incisions: triangular flap of skin, _a_ _b_ _c_, and triangular flap of fat. (Halsted.)]

[Illustration: FIG. 528

Breast and pectoral muscle completely separated from thorax; axilla exposed. (Halsted.)]

The operation as thus described has been extended by Halsted to a degree which requires often much more work, and which has furnished even better results, since he includes in it, if necessary, the removal of both pectoral muscles, and even the division of the clavicle for better exposure of the axillary and lower cervical regions, and the more thorough extirpation of involved lymphatics. In other cases he makes a vertical incision along the posterior margin of the sternomastoid, exposing the junction of the internal jugular and subclavian veins, and removes the supraclavicular fat by a downward dissection and the infraclavicular fat by a dissection from below. This is facilitated by elevating the shoulder, by which the clavicle can be removed one inch or more from the first rib.

Figs. 527 and 528 illustrate the incision recommended by Halsted and the general method of attack.

Throughout these operations the primary question is removal of disease, the matter of subsequent closure of the wound being a secondary consideration. Nevertheless the extirpation being completed, there arises the question of how best to close the extensive defect thus created. This will depend on its size and upon the amount of loose skin in the vicinity furnished by the patient’s general physique. With emaciated patients, whose skin is tightly drawn, it is not easy to furnish flaps, whereas in those who are fatty, with flabby flesh and skin, it is easy to rearrange the latter. Beck has suggested to make quadrilateral instead of elliptical incisions, leaving a square defect, which can then be closed by sliding flaps from two directions. The names of Warren and Meyer are also connected with elaborately described plastic operations. Years before any of these were published the writer was doing similar sliding of flaps, but never endeavoring to make them conform to a single pattern, raising semilunar flaps, or those of any other shape, as might best fill the demand, and taking them from that portion of the thorax, side, or even the abdomen, which would seem best to furnish them. There is, therefore, no one method to be especially recommended, for every operator of good judgment will be able to secure sufficient integument from some surrounding location, so that it is rarely necessary to leave such a wound uncovered. In those cases which require an amount of dissection not permitting this it is a question if operation be advisable. Nevertheless should it happen that for some reason a sufficient skin covering is not thus easily available, Thiersch skin grafts may be applied to any uncovered area at the time of terminating the operation or later, and may be nearly always relied upon for their destined purpose.

At least one opening should be made in the lateral flap in such a location as to drain the axillary cavity when the patient is lying upon her back, and through this a drainage tube of sufficient size should be inserted. This should rarely be left more than forty-eight hours. Inasmuch as there will sometimes be considerable tension upon flaps a certain number of strong and reliable sutures (silkworm or thread) should be used, to prevent parting of the wound margins, while long retention sutures may be inserted if required. The balance of the suturing may easily be done with catgut. The intent should be to leave no dead spaces. Any isolated mass of fat which stands out by itself after the dissection is complete should be pared down to the common level, in order that it may not perish from ill-nutrition, nor disturb the general level of the adjoining surfaces. It is rarely necessary to keep patients in bed more than two or three days after even extensive operations of this kind, but it is necessary to ensure that equable pressure be made with the dressings, and that the entire arm be bound to the side and immobilized in such a way that the patient cannot move it nor disturb the dressing.

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