CHAPTER XXXIV DIAGNOSIS OF DISEASES OF THE (Part 1)

CHAPTER XXXIV DIAGNOSIS OF DISEASES OF THE BREAST The importance, and often the difficulty, of correct diagnosis of affections of the breast are so generally recognized that it is not needful to insist upon those facts here. It may be well to impress upon the student the necessity of bearing in mind the physio- logical changes occurring in this gland. The earliest of these is the slight engorgement, with consequent swelling, slight tenderness and induration, that may be observed a few days after birth, often more marked in male than in female children. In this state inflammation is readily set up by injudicious friction, and abscess may result. In girls at puberty the gland usually undergoes a considerable but variable degree of enlargement, the nipple develops and the areola becomes broader and better marked. The commence- ment of this change, particularly if it occurs on one side earlier than on the other, may be mistaken for the development of a tumour, but a proper examin- ation will exclude the error, and a consideration of the patient's age will at once suggest the true nature of the case, which will be further cleared up by time. At or soon after this period it is not uncommon to see acute suppuration under the skin of the areola or that covering the mamma proper. In males at this age there is often noticed an abortive development of the gland, giving rise to a small, firm, disk-shaped 471 472 SURGICAL DIAGNOSIS [cuap. swelling under tlie nipple, which may be a little tender to pressure. A knowledge of this fact will prevent any error of diagnosis ; the swelling is not always bilateral, and, if bilateral, not always symmetrical. The full evolution of the gland only occurs during pregnancy and lactation, and is followed by a corre- sponding involution. The only one of these changes that requires mention here is the formation of small, firm, rounded nodules caused by the full development of the acini of the gland ; the distinctness with which these are to be felt increases towards the end of pregnancy, and varies with the amount of fat around the lobules or imder the skin. Simple tumours may originate at this period, but cancer only rarely. Occasionally abscess is met with in a lobe of the gland during pregnancy. During lactation inflam- matory troubles and abscess become very frequent ; and rapidly growing carcinoma is occasionally seen at this time. At the climacteric the gland undergoes extensive involution ; the acini become smaller and eventually disappear. It is during this period of involution of the gland that cysts and cancerous tumours most frequently develop. Examination op the Breast The patient should be seated on a chair before a good light, the shoulders weU supported. The sur- geon should then examine the parts in the following order : (1 ) The nipple, (2) the areola, (3) the skin over the breast, (4) the gland itself, and (5) the lymphatic glands. 1. Examine the nipple, noticing its j^osition, wliether displaced in any direction, and, if so, whether it is drawn towards, or pushed aside by, a lump or swelling ; its size, whether large, small, or rudi- xxxiv] EXAMINATION OF BREAST 473 mentary ; its shafe, whether prominent, flattened, inverted, or retracted, and whether it is bound do\vn to any part of the gland ; its surface, whether in- flamed, discharging, ulcerated, covered with scabs, or dotted over with firm bright specks ; and whether there is any discharge from its ducts — milky, serous, or bloody — and if the discharge is made to flow by pressure upon any particular part of the areola or breast. If the shape of the nipple is abnormal, inquire whether it is a malformation or an acquired deformity : malformations, especially retraction and inversion, may cause obstruction to the outflow of milk, milk-congestion, and^mammary abscess ; where retraction is acquired, it indicates a dragging upon the galactophorous ducts. If there is discharge, care must be taken to determine whether it flows from the ducts which open on the top of the nipple, or exudes from inflamed or idcerated skin covering the ducts ; this is decided by the presence of cracks or fissures, by the efEects of compression of the gland, and by noticing whether the discharge flows from the top or the sides of the nipple. 2. Examine the ai-eola. — During pregnancy and lactation the large sebaceous glands in the skin may form quite marked projections from the surface ; these must not be mistaken for pathological appear- ances. Any redness or swelling of the part is to be carefully taken note of, as well as the presence of discharge or scales of any kind and the adhesion of the skin to a subjacent swelling. Sometimes dikda- iions of the galacloyhorous duels can be recognized both by sight and by touch as smooth, soft, pyriform swellings under the thin skin of this region. Abscess sebaceous cyst, hard chancre, mucous patch, eczema', I'aget's disease, and carcinoma may be found in this situaLiun. 474 SURGICAL DIAGNOSIS [chap 3. Examine the skin over the breast. — Notice any change in its colour or texture, any discharge, swelling, oedema, pointing, puckering, oi ulceration. Gently raise a fold of skin and try to glide it over the gland, and compare the ease with which this can be done on the two sides. Then gently take the breast between the fingers and thumb and try to move it under the skin, and notice any dimpling of the skin thus caused. Loss of the usual mobility of the skin over the gland is dye to shortening or loss of elasticity of the suspensory ligaments of Cooper, resulting from their deeper ends being drawn upon by a contracting growth, or by an infiltration extending along them. This sign — dimpling of the skin — is therefore an exceedingly important indication of the nature of an underlying growth. The definite adhesion of the skin to the parts beneath may be caused by inflammatory infiltration or by the extension of a growth into the skin. The skin should also be carefully examined for any small nodules in it, and undue sensitiveness should be noted. 4. Examine Hie mammary jjlaud. — First look at t lie breast and observe its size, whether smaller or larger than its fellow ; its shape, whether normal, gathered in to itself, or misshapen ; its fosiiion, whether displaced in any directioii. In some cases the efiect of disease is so closely like that of a surgica removal that the student may easily be deceived on the point. Then feel the breast with the palmar surface of the fingers pressed flat towards the ribs, and notice Avhether the consistence and " feel " of the gland is uniform, or whether llierc is a lump or mass which the flat fingers appreciate as differ- ing in consistence from the rest of the breast : if so, we say there is a " iumour " in the breast. It xxxiv] EXAMINATION OF BREAST 475 is very important to remember that the presence of a tumour must never be determined by what is felt when the breast is grasped between the fingers and the thumb ; when examined in tliat way a healthy breast may give the sensation of a tumour. Only after the presence or absence of a tumour has been determined hj the hand placed flat upon the breast must the gland be examined in any other way. If there is nothing that can be identified as a " tumour,'' feel carefully the consistence of the gland and note any fine nodular unevenness, such as would be caused by distended or enlarged acini, or if any part or the whole of the gland feels firmer than it should. Then examine the mobility of the breast over the chest-wall. Get the patient to press the palms of her hands firmly together, and so to fix the pectoral muscles by putting them into strong contraction, then notice to what extent this limits the range within which the mamma can be moved. The healthy breast affords a ready standard of com- parison : it will be found that fixing the pectoral muscle always limits to some extent the mobility of the mamma ; but in cases where either inflamma- tion or a growth has extended from the gland to the fascia over the muscle, the breast becomes as fixed as the muscle. 5. Examine the lymphatic (jiauds. — The ex- amination should be made with the patient sittiu" or standing, the arm partly abducted and held by an assistant, so that the patient's muscles are re- laxed ; the surgeon, sitting or standing in front of the patient, should pass his fingers to the top of the axilla and first gently feel all the tissues be- tween the skin and the ribs as he passes his fin<fers down; and then a similar examination of the an- terior, posterior, and outer walls of the space should SURaiCAL DTAaNOSIS [cnAr. be made. Tlie size, consistence, and fixity of the glands are the points to be noticed. Compare them with those in the opposite axilla. Do not mistake the edge of the pectoral muscle or a rib for an en- larged gland, nor a hard fixed gland or mass of glaud.s for a rib ; a more common error is to miss an en- larged gland by not exj^loring the whole axilla. It is very diiEcult to feel a small firm gland in a fat axilla, and a firm gland adherent to a rib may be very readily overlooked. Having explored the axilla, stand behind the patient and examine the glands immediately below and above the clavicle, comparing carefully the two sides. It should be remembered that the axil- lary glands are enlarged during and shortly after lactation ; they are also enlarged by inflammation of the breast or of the skin over it, and they may be the seat of disease quite independent of that in the breast, such as tubercle or lymphadenoma. Tumour o£ the breast. — Having decided that there is a tumour in the breast, the surgeon should continue the examination to ascertain the following facts about it : 1. Its relation to the gland. — The first and most important fact to determine about any breast tumour is whether it is fixed to a part of the breast, or is merely lying within the gland but not adherent to it. Notice first the outline of the tumour, whether it is sharply defined or gradually fades ofi into the gland, and then, fixing the breast by pressing it against the chest- wall on either side of the tumour with the fingers of one hand, attempt to move the tumour with the other ; sometimes by passing the fingers over the surface one can feel a tumour moving in the gland, or, on the other hand, can ajipreciate that it is absolutely fixed to it. It may, however, xxxiv] EXAMINATION OF BREAST 477 be quite difficult to determine this very important point. While making tL.s examination, notice the part of the gland in which the tumour lies. All malignant (jtoivlhs, abscesses, cysts, and granulomala are inseparahly allached to, and form jjart of, tlie gland ; fibromata and adenomata, on the other hand, if of any .size, are cncapsulcd growths lying more or less loosely in the gland. This single observation, there- fore, may at once narrow down the diagnosis very materially. 2. Consistence of the tumour. — Next determine whether the tumour is solid or fluid. Notice its out- line, whether rounded and clearly defined, smooth, and miiformly tense, like a cyst ; uneven on the sur- face, like a fibro-adenoma ; flatter, firm, and only sUghtly nodular, like many cases of scirrhus. Feel carefully for fluctuation, or elasticity, bearing in mind that this may be very difficidt to appreciate in very small or very tense cysts, in cysts lying deep in full mammse, and in deep abscesses. A soft sarcoma may give a perfect sense of fluctuation. Where there is doubt whether a tumour is solid or fluid, it should always be punctured with an exploring syringe ; if fluid is withdrawn the cavity should be emptied to determine whether, as a result, the tumour has wholly or only partially disappeared. The firmness of carcinoma is one of its very important features, and the detection of a firm nodule or edge will often enable the recognition of a scirrhous growth in a larger area of chronic mastitis. 3. Influence of the tumour upon the breast and surround- ing tissues. — Under this heading there are three dis- tinct points : (a) Evidence of infiUraiion in the fact of the tumour extending beyond the gland in which it arose into the fat around, the skin over, or the muscle SURGICAL DIAGNOSIS [chap. beneath it. This infiltration is only seen in malig- nant growths and in certain cases of inflammation — it is therefore an extremely valuable aid to diag- nosis, {b) Contraction. Many sweUings as they en- large displace the surromiding tissues ; but with the development of most cases of scirrhus, contraction of the growth occurs, and, as the periphery of the tumour is always fixed to the tissue in which it grows, the contraction tells upon these tissues and so causes retraction of the nipple when galactophorous ducts are involved, or dimpling or more marked pucker- ing of the skin over it ; m some cases the whole gland is shrunken and drawn in towards the growth. To recognize that a tumour contracts as it develops is a most important step in diagnosis, (c) (Edema. Occasionally there is found a little oedema of the skin and subcutaneous tissue over a lump in the breast ; it is evidence of inflammation, and may aid in the recognition of a chronic abscess. 4. Evidence of infectivity. — Carcinoma infects the axillary glands at a venj early period ; it is rare to meet with a case of scirrhus in which a careful examination of the axilla does ]iot reveal at any rate some hardeiuiig and enlargement of a gland. The infected gland may be single, or there may be several enlarged glands more or less closely matted together. Evidence of the infective nature of the tumour may also be found in secondary nodules of growth in the skin over and around it, and later on in distant parts, such as tlic liver, lungs, ovaries, and l)ones. 5. The shape of the tumour should be noticed, whether globular or ovoid, squarish, lobed or iinely lobulated. Cysts and abscesses arc rounded m outhne ; cancer is often cubical ; fibro-adenomata are usually XXX [v] ENLARGEMENT OF BEE AST 479 finely lobiilated. Chronic mastitis may cause a swelling of one or more of the lobes of the breast, or it may have a very irregular outline. 6. Number of !he tumours. — Cysts are often mul- tiple, fibromata are frequently so ; occasionally more than one chrouic abscess may be found, very rarely is more than one primary sciirhoiis growth seen. There miy l)e a simultaneous development of scirrhiis in the two breasts. 7. The history of the case, including the sex and age of the patient, the occurrence of pregnancy, mis- carriage, lactation, and the duration and rate of growth of the tumour, are all points to be carefully noted. The part having been examined in this systematic manner, cases of mammary disease can be readily grouped as follows : Cases of acute enlargement of the breast. Cases of chronic disease other than tumour. Cases of tumour of the breast. The individual members of each group may be diagnosed by attention to the points about to be enunierated. A. Cases of Acute Enlargement of the Breast 1. If in a nursing woman a lobe of the gland or the whole breast is swollen and firm, the surface bein" irregular owing to the distension of the glandular acini, the skin not reddened nor fixed to the gland and the part not acutely painful or tender nor the' body temperature raised, it is a case of milk-congestion. Examine the nipple carefully for any cause of obstruc- tion to a duct or ducts. The axillary glands will be found slightly enlarged. 480 SURGICAL DIAGNOSIS [fHAr. 2. If the breast is acutely painful and tender, the skin over it bright red in colour, and the outline of the glandular tissue blurred by 03dema, it is a case of acute mastitis. The temperature is raised, and there are the usual signs of inflammatory fever. The axillary glands are enlarged and tender.^ 3. If in such a case the swelhng is " pomtmg, or is found to fluctuate, there is a mammary abscess. In the absence of these signs an abscess is to be diagnosed if the swelling has increased after the first, if the area of redness has extended, if the tension is great, if the pain has become throbbing, or if there is marked subcutaneous cedema. 4. If the breast is prominent, the skin stretched, and the nipple pointing, and if pressing the gland back against the chest causes pain and gives a yield- ing sensation as of fluid under the mamma, and particularly if there is a swelUng at the axillary border of the gland, which becomes more tense and prominent when the gland is pressed back, the diagnosis of submammary abscess sliould be made Such an abscess may be acute or chronic. When - acute it is secondary to mammary abscess or to a wound of the part. Chronic submammary abscess is either tuberculous or mycotic. Tuberculous abscesses are generaUy secondary to disease of ribs ; actinomycosis in this situation appears to be always secondary to the disease in the limg. )^hen in any case of mammary abscess pus is lound pointing at the margin of the gland, or