CHAPTER XXXIV DIAGNOSIS OF DISEASES OF THE (Part 2)

smuse^ are • here met with along which a probe passes deep to the gland, it is evident that submammary suppuration has occurred. r ,i i ;„ 5. An acute swellmg with redness of the skm, superficial oedema, and the speedy development ot a fluctuating and pointing swellmg, without enlarge- xxxTv] CHRONIC DISEASES OF BREAST 481 mont and hardening of tlic mamma itself, is a sub- cutaneous or supramammary abscess. G. If the breast has rapidly become enlarged and firm, and the skin over it is red and fixed to the gland, and the gland i« fixed to tlie chest-wall, and the axillary glands arc enlarged and firm, it is a case of acute carcinoma. The rapid swelling, the redness of the skin, and the accompanying pyrexia make the case closely resemble acute mastitis, and this mis- take is almost invariably made at first, particu- larly when, as often happens, the patient is preg- nant or nursing. The absence of softening, the detection of a nodule or some other irregularity of the surface, and the invasion of the skin and of the chest-wall are the signs to be particularly relied upon in the diagnosis. Later, the spread of the disease to the glands in the neck or to other parts makes the diagnosis only too plain. This foi ra of the disease may run its entire course in three or four months. B. Cases of Chronic Disease other than Tumour 1. If both glands are found to be unusually largo, not pauaful, nor inconvenient except from their bulk and weight, and of normal consistence, the condition is hypertrophy. Remembering that' without overstepping the Hmits of health, the breast attains a great size in some women, this diagnosis must only be made when the glands have attained really excessive dimensions. Two forms are to be recognized, in one of which the gland is very loose, soft, and pendulous, while in the other it is firmer' tenser, and projects forwards. Hypertrophy is' generally bilateral, but not always symmetrical ; it is most common in young women, the growth starting at puberty. ° <4 482 SURGICAL DIAGNOSIS [chap. 2. When the nipple is red, painful, very ten- der, and sero-purulent fluid is found exuding from cracks or fissures, the condition is known as cracked nipple ; ulceration is commonest at the tip and round the base of the part. Wh.-n the watery discharge dries into thin yellowish scales, the skin beneath these being red and itching but not acutely pamful and tender, it is eczema of the nipple. Small white projections on the top of the nipple are epithelial plugs in the ducts. 3. If there is a discharge of serous fluid from the nipple, determine by careful pressure with the finger-tip exactly the spot fi-om which this secretion comes, and then feel very carefully for any small nodule ; if such can be felt the case is one of duct papilloma ; if no nodule whatever is to be felt the • S3cretion is from a dilated duct. If, however, the dis- charge is always or occasionally blood, it points to the presence of a duct carcinoma (see p. 487). 4. If the skin is red, discharging a watery fluid which stiffens linen and dri:s into yellowish scabs, the condition is eczema. 5. A very chronic eczematous condition ot the areola and surrounding skin is known as Paget's disea-e. The affected surface may be dusky in colour with dry adherent scales, or bright red and moist with a constant watery discharge, in eithei case, its area slowly but progressively enlarges This peculiar condition of the surface of the breast is always to be considered as definite evidence of the presence in the breast of a carcinoma although the clinical appearance of a " lump in the breast may be delayed for months or everi years. 6. If a part or parts of a breast feel firmer than normal, but do not give the sensation of a tumour when the flat hand is pressed upon the part, ana xxxiv] CHEONIC MASTITIS 483 the skin is not at all dimpled over it, nor the mobility of the gland lessened, it is a case of chronic mastitis. The affected part may be mieven, from the develop- ment of small cysts within it. One or more of the glands in the axilla may be a little enlarged. This affection is common in women between 30 and 50 years of age ; it may be very difficult to distinguish from early carcinoma, and it may be the starting- point of carcinoma. Chronic mastitis is often pre- sent in both breasts at the same time, and often attacks more than one part of a breast ; but neither of these features is quite distinctive, as carcinoma may attack both breasts simultaneously or be mul- tiple in one breast, and, further, it may develop in one of two or more areas of mastitis. Mastitis is less sharply defined than scirrhus, and does not feel so distinctly a nodule in the gland. In many cases mastitis yields rather quickly to treatment by firm compression; scirrhus does not, but, on the other hand, becomes more salient in the gland. This has often proved usefid in diagnosis. When, in spite of careful examination, the surgeon is in doubt, he should excise the portion of the breast containing the suspicious area and examine it under the microscope. 7. If, without redness of the skin or other sif^n of inflammation, gentle contact of the hand causes pain, there is hypersesthesia of the mamma. If this tenderness involves the whole region, and if it is especially marked over the points of exit of the anterior and lateral cutaneous nerves of the second third, fourth, and fifth intercostal spaces, and if the pain radiates to the back and shoulder, it may be diagnosed as neuralgia. But if the pain is elicited by contact with certain spots only of the breast, and further, if at these spots small, firm, round or 'ovoid 484 SURGICAL DIAGNOSIS [chap. tumours movable under tlie skin and over the breast in one direction are felt, and pressure upon them causes acute pain radiating over the mamma, the tumours may be recognized as neuromata, and as the source of the hyper assthesia. C. Cases of Tumour op the Breast 1 The tumour is movable in tlie breast tissue.— («) If the tumour is movable in the breast tissue and is firm in consistence, it is a fibro-adenoma. A distmct ovoid and lobulated outline and slow rate of growtia are other characteristic features of these tumours. They may be found in both breasts or multiple m one breast. The patients are usually young women. The one special distinguishmg feature of this tumour is that it is not an infiltrating growth and is not fixed in the breast tissue. The firmer the tumour the .greater the proportion of fibrous tissue m it. (I) A tumour which, like the above, is movable in the breast tissue but is softer in consistence and finely lobulated is an adenoma. These tumours are rare • they resemble the healthy gland m structure and consistence ; they may attain considerable size, displacing the breast to one side and forming the chief part of the prominence of the bosom. ^ • 2 The tumour fluctuates.— (a) If the swel mg ha. arisen during pregnancy or lactation, is g obular m outline, and uniform in consistence, without any sign of infiammation, it is a galactocelc or ^n^lk-cy . These tumours are usually in the central part of the gland and painless. . n^,,.!,, (b) If the swelling has arisen mdependently oi lactation, and without any evidence of inflammation and there is no sign of infection of ly^pl^'^^jc «^ Burroimdmg tissue, it '«^^^«'""""''?^^'^;,,,,Hrm cysts are frequently multiple, and vary much m xxxrv] TUMOUR OF BREAST 485 size ; they are most common in women from 30 to 50 years of age ; when very small and numerous they give a shotty feeling to the breast. (c) If a small lump which has been known to be present for many years takes on rapid growth, or if from its first appearance a swelling grows rapidly, at first as a single cyst, later becoming irregular in outline with cystic projections, is painless and un- accompanied by glandular enlargement, it is a cijst- adenoma, or Brodie's tumour. These tumours may attain a great size, and as the tumour enlarges, the skin over it may give way and a fuugating, easily bleeding mass protrude. Such a growth is dis- tinguished from a malignant tumour by the fact that the skin is not involved in the growth ; a j^robe can be passed between the thinned skin and the intracystic portion of the growth. (d) If the swelling has arisen durmg lactation or after a miscarriage, and has an ill-defined outline, and especially if there is oedema over it, or the part has been or is painful, it is a chronic abscess. This is most often found in the peripheral part of the gland. (e) If the fluctuating swelling began as a small, painless, solid nodule, and has slowly become larger, fluid, and more superficial, and the patient is the' subject of tuberculosis elsewhere, it is a chronic tuberculous abscess. In these cases the glands in the axilla may also be tuberculous. In some cases an exact diagnosis can only be made if the swelling is pimctured and its contents are drawn off and examined. The fluid may be pus, tuberculous debiis, may contain a streptothrix (actmomyces), turbid brownish or greenish mucous fluid, milk, or the clear watery fluid of a hydatid cyst in which hooklets can be found, 486 SUKGICAL DIAGNOSIS [n^^v. 3 The tumour is incorporated with the breast and is solid.— («) If in a middle-aged or elderly patient there is oir the nipple a chronic ulcer with firm thickened, warty edge, and pink, irregular, indurated base, discharging ichorous lluid, and if the induration and the ulceration steadily increase m area, while the glands in the axilla are enlarged and hard, the disease is epithelioma of tJie niffle. (M If there is a firm, flat, disc-like lump m the areola with a well-defined rounded edge, and the skin oVer it is fixed to this lump, and one or more enlarged and firm glands are felt in the axilla, it is a carcinoma. Later on the skm ulcerates. (c) If the tumour is fixed in the breast tissue, is solid but does not show any evidence of mfectiou of lymphatics, it is a sarcoma. These tumours are usually globular in outline, grow rapidly, and form prominent masses. In some cases they grow slowly for a time. They may be so soft as to fluctuate, but if they are pmictured, only blood is drawn oii ; or cysts may develop in the tumour contammg dis- coloured serous flmd. Later on these tumours may fungate through an ulcer in the skm, but they do not involve the skin in their growth so rapidly or extensively as carcinoma does. id) If 'the tumour is fixed in the breast tissue, beneath or close to the areola, and is attended with a discharge from the nipple, it is cither a simple distended duct, a duct papilloma, or a c^^ct car- cinoma. If the discharge is serous only, and by gentle pressure it is emptied and nothmg can b. felt of the swelling, it is a cUatcd galaclophowv. '^'%) If the tumour is very small and soft, but can- not be dispersed by gentle pressure, and the f^^J^ from the ni])ple is sometimes serum and sometimob xxxiv] SCIRRHOUS CARCINOMA 487 blood, and especially if these symptoms have existed for many months or years, it is a duct fafilloma. if) But if the tumour is enlarging, or has reached the size of a pea, and is at all firm, and especially if an enlarged gland can be felt in the axilla, it is a duct carcinoma. (g) If the tumour is fixed in the gland tissue, is solid, and has infected the lymphatic glands, or has caused dimpling of the slcin over it, or retrac- tion of the nipple, or tilting of the nipple towards the tumour, it is a scirrhous or sj^heroidal-ceUed carcinoma. Scirrhous carciuoma.— As this is the variety of tumour of which the diagnosis is of most moment, the characters to be especially recognized may be further pointed out. Clinical features.— The first and most important of these IS the mfiUraiinj mode of groiuth. Beginning m the gland, it is from the first absolutely fixed to it and immovable apart from it, and as it enlarges it infiltrates and becomes fixed in a similar manner to the skin over it and to the muscles beneath it ; but these latter phenomena are observed only when the tumour has reached a certain size, and with very varying rapidity in different cases. Whenever this characteristic is well marked, scirrhus must be diagnosed unless absolutely contraindicated Contraction of the growth leads to dragging upon the galactophorous ducts and retraction of the nipple and also to puckering-in of the skin over the tumour' The stage at which this feature can be recognized depends upon the situation of the growth: the more superficial it is, the earlier is dimpling of the skin ob.servable; the more central the growth, the earlier is the nipple retracted. In some cases contraction IS very marked ; it is always a noteworthy symptom 488 SURCIICAL DIAGNOSIS [chap. Glandular infection takes place early and very constaatly. The affected glands like the primary tumour, are firmer than normal, and usually pro- gressively enlarge. There is great varia ion m the rapidity with which successive glands become in- fected, and also m the relative size of the primary and secondary growths. It is important to x;eniembe that when the original growth is near the inner margin of the breast, the glands of the opposite axilla may be involved quite early. In addition to these signs, which may be called the cardinal signs of scirrhus, there are other pheno- mena of less constant occurrence but of diagnostic value when observed. Of these may be mentioned especially : Paqet's disease of the s/cm.-When a tumour is found in the breast associated with, and developed ubsequently to, this form of chronic incurable eczema, it may with certamty be diagnosed as cancer. , Nodular growths in the ./.m.-The presence o firm nodules in the skm over and around the tumour in the breast is eminently characteristic. Vlceration may be a striking feature, and the point to which attention should be directed ^ the skin is implicated m the growth before it bieak down, or whether, from pressure upon it, a poitioi of Tt slou.hs or ulcerates and allows the subjacent ^imoiu Jof ungate. This can be readily ascertamod from the character of the edge of the ulcei. Infiltration of the skin by growth befoi^ idcera- tion is characteristic of carcinoma Fmigation o a tumour through greatly thinned but non- nh - trated skin is sometimes seen m sarcoma oi cjst adenoma. . - xxxiv] .SOIRRTIOUS C'AKC!INOMA 489 The facts in relation to age, heredity, pain, and cachexia are not of a nature to aid materially in the diagnosis in cases otherwise obscure. Varieties of scirrlius. — Sciirhus occurs in the breast in several forms, and the following varieties at least can be clearly recognized : 1. The tuberous, where a distinct tumour is de- veloped which grows steadily, and in which progressive new formation is the most characteristic feature. 2. The ulcerative, in which the growth quickly and widely ulcerates. 3. The cicatricial, characterized by slow develop- ment, and great contraction of the growth, which draws in towards itself all the surrounding parts, making a deep pucker in the breast or subcutaneous tissues. 4. The atrophic form, an exagge;ation of the last. The growth of this is very slow, the tumour very small and very firm, ulceration is postponed for a long time even if it ever occurs, lymphatic infection is slow and mild, and the whole disease lasts for many years. The subjects of this form are usually of advanced years. 5. The lympliatic form, in which, with a small, slowly progressing primary growth, there is rapid and extensive infection of lymphatic glands, which is the chief source of the patient's sufferings. 6. Cancer " en cuimsse," in which the growth occurs widely in the skin in the form of scattered nodules, spreading and quickly running together into an unyielding cuirass-like casing of the chest. 7. The acute form, which has already been de- scribed {see p. 481). In certain cases the nature of a tumour in the breast is seldom if ever determined before removal and apart from microscopical examination, e.g. very 490 SURGICAL DIAflNOSlS small tumours, and endothelioma, enchondroma, myxoma, gumma, hydatid and lymphatic cyst. Diseases oi the male breast. — Chronic mas- titis, spheroidal-celled carcinoma, squamous epithe- lioma, cysts, and sarcoma occur in the male, and are to be recognized by the same features as in the female. Owing to tlie small size of the mamma in the male it is more difficult to distinguish between chronic mastitis and early carcinoma than in the female. Infiltration of. the skin, a nodular outline of the lump, and enlargement of the lymphatic glands are the diagnostic signs of carcinoma.