in small amount in the normal breast, and is the same kind of tissue found in the pericanalicular fibroma. It exists in this case in large enough amount in places to simulate very closely the above-named tumor. In these supporting tissues is found a very greatly increased number of capillary blood vessels, around which, as seen both in cross and longitudinal section, are very many round cells. These capillaries are found in unusual number running up to and communicating with the vessel surrounding the duct. There is in fact a very general round-celled infiltration of the entire stroma, and the interlobular tissue looks like indurating granulation tis sue. may say here that the picture is largely one of hypertrophy and chronic inflammation. Hypertrophy of the breast, for the purpose of lactation, presents a very different histological picture from the hypertrophy occurring apart from that period. In the former there is an increase of true glandular tissue, the acini being increased both in number and size; the peculiar periductal and intralobular tissue has almost disappeared. In the hypertrophy occurring apart from lactation there is an increase of the periductal tissue. It is an increase of constituents in the proportion in which they are found in the young girl's breast. There is at that age an imperfect development of acini, the gland consisting largely of branching ducts with some lateral budding. In this form of hypertrophy the newly-formed glandular tissue should be capable of lactation in the event of pregnancy. This form of hypertrophy has been spoken of also as diffuse adenoma. A circumscribed form has also been described. Probably it is a true adenomatous formation. Concerning the mastitis part of this condition. The number of names given to chronic mastitis indicates the uncertainty of opinion regarding its nature. They areI. Chronic cirrhosing mastitis.-Billroth. 2. Chronic cystic mastitis.-Konig. 3. Intra-acinous cystic epithelioma.-Reclus. Cyst adenoma.-Schimmelbusch. 4. 5. 6. 7. 8. 9. Cystic disease of the breast.-Bryant. Chronic interstitial mastitis. Ziegler in his last edition dismisses the subject as follows: "As well as tuberculous and syphilitic mastitis there is a chronic mastitis formed partially of granulation tissue and partly due to indurating connective tissue whose etiology is unknown." Banks says it is not a sequel of acute inflammation. König believes that it is an independent disease, and due to changes originating within the lumina, the interstitial changes being secondary, the minute cysts not being always due to pressure of increasing interstitial tissue. Greenough and Hartwell, in the Journal of Medical Research for 1903, after analyzing a large number of cases, think that mastitis as applied to this condition should not imply an inflammation of bacterial origin, but rather an increase of fibrous tissue of other than local tumor origin, and that the formation of cysts and proliferation of the epithelium are the striking features of the disease. All are agreed that chronic cystic mastitis is prone. to carcinomatous change. The breasts of infants are very commonly the subjects of swelling and redness about the fourth or fifth day. Kölliker explains this by the physiological development of the breast at this time, the breast at birth consisting simply of solid columns of cells. In a few days the central cells of these columns undergo degeneration, and the hypremia and swelling are due to changes brought about by this process. At puberty, in both boys and girls, a similar inflammatory-like swelling is frequently seen. This again occurs at a time when physiological changes take place in the gland. The onset of lactation is very constantly marked by symptoms of an inflammatory character. It is still a matter of controversy as to whether this is due to bacterial invasion or to the disturbance incident to so great an increase of function. The case, the histological report of which has been. given, cannot be said to conform to the definition of chronic cystic or interstitial mastitis recognized as an independent disease, nor can it be said to be pure hypertrophy. Among a very large collection of tumors and enlargements of the male breast by Schuchardt are 60 cases in males of 16 to 20 years of age in which the clinical description is pretty much like ours. In a few the symptoms were quite acute. He classified these as a mixture of hypertrophy and inflammation, but as they all got well in a few weeks no histological description is given. Shields, in his book on diseases of the breast, refers to a specimen in the museum of University College Hospital whose gross and minute description is given, and corresponds very closely to our case. He says the condition seems to be one of hypertrophy with great overgrowth of fibrous tissue, that the causes of induration in the male breast are often obscure, and that some cases in our museums termed hypertrophy of the male mamma are likely enough chronic inflammation. The nature, therefore, of enlargements of the male breast which I have been able to find described whose clinical description corresponds to the one reported, has been benign. Occurring, however, at the age when the mammary gland should undergo atrophic changes makes tumors of the breast suspicious of vicious possibilities. There is already a change in the cells within the lumina of the ducts, indicative of an unusual epithelial activity, which is found neither in lactation nor in the ordinary hypertrophy, which, according to Borst, must be an imitation of normal breast structure as found in the virgin breast. This certainly does not possess that simple picture. There is sufficient departure from it to warrant us in saying that the hypertrophy is at least atypical. Von Angerer in the "Hand-Book of Surgery" by Von Bergman says that the benignancy of many mammary tumors is only a relative one, and that from this standpoint we are justified in the early removal of all mammary tumors. The real meaning of this would seem to be that we are not yet always able to recognize malignancy. Morphology does not reveal the life-history of cells. Hansemann says a difference in the parenchymatous cells of hyperplastic gland growth, ordinary adenoma, and malignant adenoma are not to be made out. He further says in his book on the "The Microscopical Diagnosis of Malignant Tumors" regarding the excising of pieces of tissue for histological diagnosis; “In characteristic cases a successful morphological diagnosis can be given, but these are the cases where the clinician without the aid of the microscope can with certainty differentiate." "For cases on the boundary line of malignancy and benignancy the microscope is also usually doubtful, and exactly in these cases an error in diagnosis is worse than no diagnosis, for it frequently influences the surgeon to adopt a course which he has not originally concluded. to follow, and which may result in injury." A celebrated clinician, questioning his students as to how he would make a diagnosis in the case of a tumor of the thigh which was shown to him clinically, received the reply that he would cut a piece out to look at it under the microscope. The teacher informed the student that we use the microscope to see what a tumor looks like after we know its nature. Banks says that if the microscope confirms the nakedeye appearance well and good, but when they differ the clinical history and gross appearance on cutting into the tumor should decide the surgeon as to his course. Shields says practically the same thing. The etiology of malignant tumors is not yet known, and until that is known we shall probably be uncertain. as to the morphology of malignancy in tumors. The growth of the so-called benign tumors is just as wonderful as the growth of malignant ones, and it is not much wonder if the one is frequently simply a forerunner of the other. Quoting Hansemann again: "So long as a tumor is in the 'becoming' stage we cannot tell what it may become, it is only carcinoma when it plainly has that structure." One must remember, however, that several tumors formerly classified as benign have been found to undergo metastasis. From what has been said it is scarcely necessary for me to add that the microscope furnishes a valuable part, but only a part, of the evidence to the surgeon in his summing up for and against malignancy in tumors of the breast. Regarding the treatment of this condition: In the case of the physician reported, the glands probably went through a series of changes from hypertrophy to involution lasting about six months. In the other case, after an observation of about the same length of time of the second breast, no evidences of involution were seen. In this case too the breasts were not simultaneously affected. The patient's age was long past that at which atrophy of the glands occur in the male. If, then, a condition of this kind, after six or eight months' observation, showed no signs of involution, it might fairly be classed among the conditions with unknown possibilities, and its removal considered justifiable; the more so that the undertaking is a minor one, and can be easily done under infiltration anesthesia. |