Section Iii. of the Mammæ.

=[Notice=: 1. External Characters—abnormalities; silvery lines on integument, indicating previous enlargement; sinuses; firm, or soft and flabby. Nipple—its size, color, retracted, ulcers; excoriations, etc. Areola—size and color. 2. Appearance on section—color of substance; consistence of gland and fluids exuding; abscesses; tumors; cysts; cancer, etc.]

=Anomalies.= Supernumerary mammæ, with the power of secreting milk during lactation, have been observed in a number of instances.

The cases of absence of one or both mammæ are rather to be classed as the result of arrest of development or atrophy.

A too early development of the glands in young children is occasionally met with, where there is a precocious development of the organs of generation.

While the mammary glands in the male usually remain in a rudimentary state during life, cases have occurred where they have acquired an increased size, and have been stimulated to such a functional activity as to permit of the suckling of an infant.

=Hypertrophy and Atrophy.= When puberty occurs, the breasts naturally enlarge and often become tender; and such a temporary enlargement very commonly accompanies menstruation.

An increase of size, such as normally takes place during pregnancy, between the fourth and ninth months, will occasionally commence at puberty, and go on until the organ attains an enormous size. In some cases the breast has been found, after death, to weigh as much as twenty pounds, the tissue being perfectly normal.

Both breasts are usually affected, although one is commonly more so than the other.

After the cessation of the menses, the breasts normally begin to atrophy.

We may also have an atrophy of the breast following upon lobular hypertrophy, as described by Sir A. Cooper.

=Inflammation and Abscess.= Inflammation of the Nipple and Areola, preceding or following a fissured state of the nipple, usually occurs at an early period of lactation, and especially with the first child. Abscess of the areola is often a consequence.

Inflammation of the Breast, generally terminating in suppuration, may occur in three positions: either in the subcutaneous areolar tissue, supramammary abscess; or in the areolar tissue, in which the gland is imbedded, submammary abscess; or in the gland itself, mammary abscess.

Chronic Abscess of the Breast may be of two kinds: the diffused and the circumscribed or encysted. The former may occur at all ages, and in the single as well as in the married. It usually appears in the submammary areolar tissue, and may acquire a very large size; and by pushing the mammary gland before it, gives the breast a pointed, conical shape.

Chronic encysted abscess, so closely simulates various tumors in this situation, as to render a diagnosis in some cases very difficult during life. It usually commences as a result of pregnancy; sometimes as a consequence of lacteal inflammation; but usually without any injury or other direct local cause. An indolent, indurated swelling forms, and this may gradually soften in the centre, although fluctuation may for a long time be very indistinct, and even absent, owing to the thick wall of plastic matter that is thrown around the collection of pus. It is not unfrequently attended with retraction of the nipple.

Syphilitic ulcers are also found affecting the nipple; while eczematous and erysipelatous inflammation in this situation are of frequent occurrence.

Morbid Growths.

The mammæ are frequently the seat of adventitious growths, presenting the characters of non-malignant and malignant formations. The most common of the benignant tumors is, perhaps, the

=Adenoid Tumor or Adenocele=. This is most frequently met with in young women under thirty years of age, seldom commencing at a later period than forty. It may remain stationary for years, or it may slowly increase or grow very rapidly to a great size. It has frequently been mistaken for cancer, but the otherwise good health of the patient, the mobility of the mass, the absence of all implication of the skin or glands, the want of hardness and its circumscribed character, are points of diagnostic value.

On removal, it appears irregularly lobulated, is encapsulated, and its cut surface has a bluish or grayish-white color, which, on exposure to the air, assumes a rosy tint. On pressure, drops of thick, creamy fluid will often exude. According to Birkett, the microscope shows it to consist of imperfectly developed hypertrophy of the glandular tissue, the terminal cells of which are filled with epithelial scales. This tumor sometimes simulates malignant disease by its extreme rapidity of growth, especially where it developes later in life. It then, after section, presents a lobulated, glistening appearance, somewhat resembling a mass of rice or sago jelly, often having cysts interspersed throughout its substance containing fluid or semi-solid glandular tissue.

In rare cases, the adenocele may return, even after extirpation of the entire mammary gland.

=Cystic Tumors.= These may occur as the unilocular cyst, or as the cysto-sarcomatous tumor.

Unilocular cysts usually occur as a small, thin sac, of about the size of a filbert, containing a clear, serous fluid, imbedded in the glandular structure of the breast, and movable under the skin. As they increase in size or become multiple, their contents may assume a greenish-brown or blackish tinge from effused blood. According to Brodie, they are originally formed by a dilatation of the lactiferous tubes.

Unilocular cysts occasionally attain an immense size at the same time that their walls remain thin and supple. In some of these instances, the fluid continues to the last, of a truly serous character; while in others, it becomes more or less glairy or mucilaginous.

Sometimes the walls of the cysts have been found to have undergone calcareous degeneration.

The cysto-sarcoma, occurs as an isolated, globular or oval, and more or less movable cyst; or there are numerous growths of this kind, varying in size from a pin’s head to a hen’s egg. The inner surface is smooth, or it presents a broad-based, lobulated, cauliflower growth or warty excrescences, and the substance of the surrounding gland is indurated and atrophied. A retraction of the nipple may also be observed. A transverse section shows a double sheath: one proper to the cyst, and the other the result of condensation of the adjoining textures. The contents are either fluid, of a limpid, opalescent, non-albuminous, or a grumous, brownish, highly albuminous character; or solid, approaching the character of a fibroid deposit, composed of a pale, compact substance, traversed by undulating fibrous lines, which imperfectly divide it into lobes of various sizes and shapes.

Hydatid cysts, containing the echinococus, occur in the female breast. The tumor is firm to the touch, and contains a clear fluid, in which the microscope detects the tenacula of the echinococus, the animalculum itself being attached to the internal wall of the cavity.

Fibrous, cartilaginous and osseous tumors, are of doubtful or very rare occurrence.

=Carcinoma.= Cancer affects the mammæ more frequently than any other organ of the body. The age from forty to fifty years seems most liable to its occurrence. According to Dr. Walshe, the left side is more frequently affected than the right, and both are but rarely involved.

All varieties of carcinoma have been met with in the breast; but scirrhus is by far the most frequent form in which it occurs primarily. The encephaloid variety is generally engrafted upon the scirrhus, although it may also be primary. The colloid form is the most rare.

Scirrhus appears as a hard, lobulated tumor, imbedded in the adipose tissue of the gland, causing adhesion to the skin and retraction of the nipple. Although at first movable, it soon becomes firmly adherent to the subadjacent parts, and involves more or less the gland tissue, the muscles of the thorax, and the adjoining glands. Instead of an isolated tumor, there may be an infiltration of the various structures of the part from the commencement. It will then have an ill-defined outline, sending out branches into the adjacent tissues, and involving in its mass the lacteal tubes and lymphatics. These become contracted and flattened into many bands, giving a peculiar appearance to this form of mammary cancer not observed in any other.

Ulceration of the skin gradually follows near the nipple; the edges of the sore are raised, everted and puckered. The surface is of a bluish-red color. A purulent, ichorous fluid, of a faint, fetid odor, is secreted; hæmorrhage may ensue, and the patient sinks from exhaustion.

The average time occupied by a scirrhus in reaching its full development is from two to three years. When the ulcerative stage has once begun, the system is soon broken, and the disease proves fatal in from six months to two years. The older the individual is at the first appearance of scirrhus, the more slowly does it pass through the various stages of its growth.

The axillary lymphatic glands are also in most cases found swollen, hard, and infiltrated with cancerous matter.

The pectoral muscles, ribs and costal cartilages are also found more or less involved; and a secondary affection of the pleura and lung is not unfrequent. We may also look for œdema of the extremity on the affected side, caused towards the termination of the disease by direct interference with the venous circulation.

The encephaloid form occurs earlier in life, and commonly runs a more rapid course. Its margin is less defined, the base of the tumor being diffused among the healthy cellular membrane, or other parts where it may be situated. It differs from scirrhus also in this: that the disease may advance to ulceration without any affection of the glands of the axilla.

The Male Mammæ.

The structure of the male mammæ resembles that of the female gland, though in a rudimentary state; hence we may find anomalies and morbid conditions in them similar to those found in the latter.

An increased number of mammæ have been met with.

Hypertrophy sometimes occurs.

There have been well authenticated instances of the secretion of milk by men.

The male breast may be the seat of non-malignant and malignant growths. Cancers, simple cysts, compound cysts, and other tumors occur, but exceptionally.