CHAPTER XXVII THE DIAGNOSIS OF DISEASES OF THE BREAST (Part 1)

CHAPTER XXVII THE DIAGNOSIS OF DISEASES OF THE BREAST Anatomy, p. 532. Age changes, p. 534 : The infantile breast, p. 534. The breast at puberty, p. 535. Lactation hypertrophy, p. 535. The senile breast, p. 536. Classification of diseases of the breast, p. 536. Anomalies, p. 538 : Complete absence of the breast, p. 538. Incomplete development of the breast, p. 538. Supernumerary mammae, p. 538. Symptomatic lesions, p. 539., Pain, areas of induration, phantom tumors, p. 539. Hypertrophies, p. 539: Infantile hypertrophy, p. 539. Galactocele, p. 539. Diffuse bilateral hypertrophy, p. 540. Senile parenchymatous hypertrophy, p. 540. Inflammations, p. 542: Mastitis, p. 542; Acute mastitis, p. 542; Mammary abscess, p. 542; Submammary abscess, p. 542. Chronic mastitis, p. 543; Chronic interstitial mastitis, p. 543; Diffuse mastitis, p. 543; Lobular mastitis, p. 542; Tuberculous mastitis, p. 543; Actinomycotic and syphilitic mastitis, p. 544. Benign tumors, p. 544: Fibro-epithelial tumors, p. 544. Epithelial tumors, p. 545. Malignant tumors, p. 545: Carcinoma, p. 545; Adenocarcinoma, p. 546; Comedo, p. 546; Colloid, p. 546; Cystic, p. 546; Intra-cystic papillomatous varieties, p. 546; Medullary carcinoma, p. 546; Scirrhous carcinoma, p. 548; Cancer cysts, p. 548; Paget 's disease of the nipple, p. 548, Sarcoma, p. 549. Diagnosis of tumors of the breast in general, p. 549: History, p. 550. Age, p. 550. Duration of the tumor, p. 551. Situation of the tumor, p. 551. Mobility of the tumor, p. 552. Inspection and palpation, p. 552. Dimpling of the skin, p. 552. Retraction of the nipple, p. 553. Enlarged glands in the axilla, p. 553. Late signs of cancer, p. 553; Discharge from the nipple, p. 553; Ulceration of the skin, p. 553; Skin metastases, p. 553; Metastases in other organs, p. 553; Enlarged supraclavicular glands, p. 554; Cachexia, p. 554; Inadvisability of making exploratory incisions, p. 554. Although diseases of the breast are commonly regarded as in the province of the surgeon, the breasts arc distinctly a part of woman's reproductive apparatus and in intimate relationship through the nervous system with the uterus, as attested by the uterine contractions induced by suckling, by the development of the breasts and their functions coincident with the growth of the uterine organs, even under abnormal conditions, by the sexual 531 532 DISEASES OF THE BREAST feelings caused by manipulation of the breasts, and finally, by the swelling and pain in the breasts associated with menstruation in the case of uterine disease; therefore we shall discuss here the diagnosis of the diseases of the mammae. ANATOMY The breasts consist of racemose glandular structures situated beneath the skin one on each side of the sternum. Each gland appears as a hemisphere projecting from the front of the thorax under the skin and covering a portion of the pectoralis major and a smaller portion of the serratus magnus muscles. The breast extends from the level of the second rib above to the level of the sixth rib below, and laterally from the margin of the sternum to the axillary line. The various lobes and lobules of which the gland is composed radiate from the nipple and extend to unequal dis- tances in different parts of the breast, sometimes forming a pro- longation of the gland tissue into the axilla, over the serratus magnus muscle, or toward the sternum. In the rare event of the occurrence of supernumerary mammae the glands are found on a line drawn from the anterior margin of the axilla downward through the nipple over the flank, the so-called "milk liner (See Fig. 200.) The nipple, cylindrical in shape and about half an inch in diameter, projects about half an inch from a point a little below and to the median side of the summit of the hemisphere. Its top is made rough by fissures and in the center is a depression in which are the openings of the milk ducts. Surrounding the nipple is the areola, a circle of pigmented, wrinkled skin, in which are sweat glands and from a dozen to twenty little elevations formed by the sebaceous glands. The mammary gland rests loosely upon the pectoral fascia, so loosely that the entire breast is freely movable. A sagittal section of the mamma shows it to be made up of gland tissue, all the ducts of which converge at the nipple ; of fat, fibrous tissue, and skin. The gland tissue is firm in texture and of a pale reddish color. There are from fifteen to twenty excretory ducts, each one coming from a lobe, every duct having a spindle-shaped dilatation ANATOMY 533 as a reservoir for milk just before it emerges from the apex of the lobe into the nipple. The lymphatic glands of the axilla receive the greater number of the lymphatic vessels of the breast and are disposed in three groups : the pectoral, at the outer margin of the pectoralis muscle ; CLAVICLE- VECTOR A LIS MAJOR FIBROUS SEPTUM GLAND SUBSTANCE-/ ADIPOSE TISSUE AREOLA NIPPLE -THIRD RIB -AREOLAR TISSUE FIRST RIB SECOND RIB PECTORALIS MINOR INTERCOSTALES SHEATH OF PEC- TORALIS MAJOR .SUPERFICIAL FASCIA -FOURTH RIB -LUNG ADIPOSE TISSUE HORIZONTAL PLANE OF NIPPLE -FIFTH RIB SIXTH RIB Fig. 197. — Vertical Section of Right Breast, Inner Surface of Outer Segment. (Testut.) the axillary proper, in the loose adipose tissue of the axilla; and the subscapular, between the scapula and the posterior wall of the thorax. The anastomosis of the lymphatics of the breast is ex- ceedingly free and it is easy to see how the skin may become in- volved early in cancer of the breast. The pectoral group of axillary lymphatic glands is the one usually first infected in this disease. 534 DISEASES OF THE BREAST AGE CHANGES The Infantile Breast. — The breast at birth consists of a nipple covered with epidermis, which differs from normal skin. The mamma is surrounded by a non-pigmented areola. On section the breast is seen to be made up of branching ducts surrounded by loose areolar tissue and fat. Longridge, who studied the mammary glands of still-born Fig. 198.— Dissection of the Lower Half of the Breast, Showing the Anatomical Arrangement of the Milk Ducts. (Jewett.) infants, found that in large children with abundance of subcuta- neous fat the breasts are usually well developed, irrespective of sex. The breast tissue can be felt distinctly as a solid mass lying below the primary areola, and on squeezing it a fluid, which on microscopic examination is indistinguishable from milk, can be expressed. Whatever the cause of the activity of growth in the breast of the new-born infant may be, and many theories have been advanced, such as the existence of a "chemical messenger" in the circulation, AGE CHANGES 535 or an internal secretion from the maternal placenta, . the growth and the secretion cease soon after birth and the breast is quiescent until puberty approaches. The Breast at Puberty. — At puberty the whole breast enlarges, the nipple becomes larger also, and is more sensitive; the areola increases in size and becomes pigmented to a moderate degree in brunettes. Acini lined with epithelium are formed by bulbous outgrowths from the ducts, and there is an increase both in the gland structures and the intralobar stroma. Lactation Hypertrophy. — The breasts become fuller, the veins are 1ST ^'C i u <s& Fig. 199.— Lymphatics of the Left Breast. (Sappey.) prominent, and the patient has a sensation of swelling of the breasts during the; second month of pregnancy and later. The nipples become prominent and the areola pigmented. In the wrinkled skin of the latter, the enlarged sebaceous glands, twelve to twenty in number, stand up as little elevations. During the fifth month there appears a secondary areola outside the primary areola, consisting of a network of pigmenl around light spots, each repre- 536 DISEASES OF THE BREAST senting a circle round the opening of a sebaceous gland. Colostrum may be pressed from the nipple by skillful stroking of the breast toward the areola after the third month of pregnancy. The secretion of milk is not established until the end of the second day of the puerperium. On section of a breast during lactation one notes that the gland structure is enormously hypertrophied, the intralobular connective-tissue stroma having, to all intents and purposes, disappeared, and the blood-vessels and lymphatics are much enlarged. The Senile Breast. — Atrophy takes place early — between thirty and forty — in the case of women whose breasts have not undergone lactation hypertrophy. In the latter event the atrophy begins with the onset of the menopause. The gland structure shrinks, but, if the woman is well nourished, fat takes its place and the breast may retain its former size. When senile atrophy is well advanced the breast consists of bands of fibrous tissue, with oc- casional remains of a duct or an acinus lined with atrophic epithe- lial cells surrounded by fat and radiating from the nipple. CLASSIFICATION OF DISEASES OF THE BREAST The following classification is taken from J. C. Bloodgood's excellent article on diseases of the female breast in Kelly and Noble's " Gynecology and Abdominal Surgery/' being based on a clinical and pathological study of 1,048 lesions of the breast, observed in the surgical pathological laboratory of the Johns Hopkins Hospital. I. Anomalies. II. Symptomatic Lesions. 1. Pain (neuralgia of breast, mastodynia). 2. Areas of congestion (phantom tumors). III. Hypertrophies. 1. Infantile (duct ectasia). 2. Puberty hypertrophy (normal). 3. Lactation hypertrophy (physiological). 4. Diffuse bilateral hypertrophy (pathological). 5. Senile parenchymatous hypertrophy, with and without cvst formation. CLASSIFICATION 537 IV. Inflammations (Mastitides). 1. Pyogenic, with abscess formation. (a) Associated with lactation. (b) Not associated with lactation. 2. Chronic interstitial, with parenchymatous atrophy and without cyst or abscess formation. 3. Tuberculosis. 4. Actinomycosis. 5. Syphilis. V. Benign Tumors. 1. Fibro-epithelial tumors: (a) Intracanalicular myxoma (periductal myxoma or fibroma- Warren) . (6) Adenofibroma. 2. Epithelial tumors: (a) Adenoma (cystadenoma). (6) Cysts with intracystic papilloma. (c) Simple cyst, single or multiple (see senile parenchy- matous hypertrophy). (d) Galactocele (see lactation hypertrophy). 3. Miscellaneous rare tumors: — lipoma, enchondroma, lymph- angioma, dermoid cysts, calcium deposits, encysted foreign bodies. VI. Malignant Tumors. 1. Carcinoma. (a) Adenoca cinoma. (b) Medullary carcinoma. (c) Scirrhus carcinoma. (d) Cancer cysts. 2. Sarcoma. (a) Secondary to intracanalicular myxoma. (b) Non-indigenous. Let us now consider briefly the different le ions of the breast that figure in the preceding classification before proceeding to a clinical diagnosis of tumors of the breast in general {w page 549). 538 DISEASES OF THE BREAST I. ANOMALIES Complete absence of the breast, usually affecting one breast only, has been described as a very rare anomaly and is due to lack of development in early embryonic life. Sometimes the ovary on the corresponding side is absent also. Incomplete development of the breast, with or without absence of the nipple, is much more common than absence and is apt to be associated with anomalies of the uterine organs. When the nipple is wanting the areola is often imperfectly formed or absent al- together. Supernumerary mammae are not very rare. They are usually near Fig. 200. — The "Milk Line" or Situation of Supernumerary Mammae, also the Breast Divided into Quadrants. (Warren.) the situation of the normal breast or in the "milk line/' (see page 532). Garre observed five developed mammae, two on the thorax, one in each axilla, and one in the median line below the ensiform cartilage. Some authorities consider that seven pairs of mammae existed originally in the human race, situated in the "milk line," three above and three below the present normal pair, and that supernumerary breasts indicate a return to a primal type. A remarkable case has been reported by Blum (Miinchen. med. Wochenschr., May 21, 1907) of a girl seventeen years old who had HYPERTROPHIES 539 two well-developed mammae in the normal situation and a third mamma in the region of the mons veneris the size of a goose egg and surmounted by seven nipples. The two normal mammae had no secretion, but four of the seven nipples of the supernumerary breast secreted a copious amount of colostrum regularly just before and during the first day of each menstruation. II. SYMPTOMATIC LESIONS Pain in the breast associated with a localized swelling is not uncommon, especially in young childless married women at the time of menstruation. The painful swelling is firm, but disappears when menstruation is over. Sometimes gynecologists see areas of induration in the breasts of patients with uterine disease. In a doubtful case of a tumor which has existed for a long time the patient should be anesthetized and careful palpation will show whether the tumor is a phantom tumor or not. If a breast tumor is found to be real, the wisest course is to remove it at the same sitting, having, of course, already gained the patient's consent, and have the tumor examined by the pathologist. Mammary neuralgia may be due to pressure on the breasts from badly fitting corsets, or from traction in the case of excessively pendent breasts, and is commonly observed in neurotic women at the time of menstruation. It occurs also in anemic women and in sexually precocious girls. Only when the pain is present in one breast alone does the symptom call for careful investigation of the breasts. III. HYPERTROPHIES Infantile hypertrophy is a rare affection due to the abnormal distention of the ducts with desquamated, degenerated epithelium. The breast at this time is more apt to become infected and mas- titis ensues often. Ordinarily the swelling of the breast subsides spontaneously. Puberty and lactation hypertrophy have been considered on page 535. Galactocele is a cystic tumor occurring during lactation and caused by the dilatation of a duct. The tumor is flask-shaped; 540 DISEASES OF THE BREAST with the mouth of the flask at the nipple. Fluctuation is present and the skin and nipple are normal. In some cases there are several of these tumors in a breast. Absence of inflammatory thickening should distinguish a galactocele from a pyogenic mas- titis. Diffuse Bilateral Hypertrophy. — Excessive enlargement of the breasts due to abnormal growth of breast tissue, a sort of adeno- fibroma, found mostly in young unmarried women, is always a bilateral disease. The increase in size is slow, requiring from one to fourteen years to attain a considerable development, and the enlargement is first noticed between eleven and thirty years of age. Occasionally the progress of these cases is rapid, as in the one re- ported by Durston, where the two breasts weighed, after removal, sixty-four and forty pounds, respectively, the growth having taken place within four months. This, I think, is the largest case on record. The enlargement begins in one breast and after a time the op- posite breast also begins to grow. The breasts are at first full and firm, but later become flaccid. The areolae are increased in diameter and the nipples become flattened by pressure. The great bulk of the breasts, which may reach nearly to the knees, may impede locomotion or even interfere with respiration. No cases of cancer occurring in diffuse bilateral hypertrophy have been recorded. Senile Parenchymatous Hypertrophy. — This disease, forming a * quarter of all the benign lesions and occurring during the cancer age, is the most important of the non-malignant tumors. The etiology is not known. The pathology consists of an increase in the parenchyma, the epithelial cells proliferating and degenerat- ing, associated with dilatation of the ducts and acini, — an adeno- matous type. In the early stage there are no symptoms, unless, possibly, pain and tenderness associated with areas of increased density in the breast. With further distention of the ducts cysts are formed, the lining epithelium being destroyed in the course of time, or the dilated ducts, instead of being filled with fluid, contain proliferating epithelial cells, — the adenocystic type. If one tumor is present it may feel like an area of induration without definite boundaries, or it may be a sharply circumscribed growth, in the latter event being at times large enough to involve an entire quarter of the breast. HYPERTROPHIES 541 Palpation will show a cystic character (the cyst being generally spherical) or perhaps a simple hard area. The nipple and the skin over the tumor are normal. If a quadrant of the breast is involved the normal contour will be altered. The adenocystic type of tumor grows rapidly, the tumor reaching a considerable size in a few days, but cases are on record where the growth had existed for several 1 V ir ;%: Fig. 201. — Diffuse Bilateral Hypertrophy of the Breasts. (Warren-Gould.) years. There may be a discharge from the nipple, and pain is a symptom of the early stages. If there are two or more tumors present in one or both breasts, the diagnosis is made by finding one circumscribed cystic tumor and several smaller shot-like tumors, generally in the opposite breast. On exploratory section a cyst has thin walls with smooth inner 542 DISEASES OF THE BREAST surface and the contents are clear and fluid, never bloody, or thick as in the case of a cancer cyst. IV. INFLAMMATIONS— MASTITIS Mastitis may be due to the Staphylococcus albus or aureus, to the tubercle bacillus, to the Spirochseta pallida of syphilis, and very rarely to the actinomyces bacillus. It is (a) acute, or (b) chronic. a. Acute mastitis occurs almost without exception during lactation and generally before the fourth month of lactation. It is more often met with in primiparae. It is probable that infection reaches the gland tissue through the nipple and the ducts in most cases, but may get there by way of the blood or from neighboring anatomical structures. The early caking of the breast during the first few days of labor seldom leads to abscess formation. At any time after this, gen- erally in the first four weeks, always before the fourth month of lactation, one or more areas of induration may be observed in one breast, attended by