The Classification of Benign Tumors of the Breast

tion of the epithelium, a shedding of the epithelial Lecture cells and an accumulation of a certain amount of granular débris in the interior of these ducts at birth. THE CLASSIFICATION OF BENIGN TUMORS It almost seeuiB as if there were something akin to an OF THE BREAST.1 inflammatory process going on in the breast at this BY J. COLLINS WARREN, M.D., LL.D., BOSTON. period. This activity in the epithelium produces a dilatation of the so that there is a sort of The with which the breast is tubes, ectaaia, great frequency and finally it is so marked that it becomes at the end afflicted with cancer, makes lesion of that a any organ of the first year a cavernous structure liued with a source of to the and to members great anxiety patient pavement epithelium. No material change iu the of the family. The importance, therefore, of a correct of the takes after this until the of all the of this is such appearance gland place knowledge growths regiou age of puberty is reached, aud then we find, of course, that it seemed to me that this would be a suit- subject an increase of in the and we able one for one of the lectures of this wiuter's growth again gland, evening notice this condition not in the female sex, but season. only also iu the male. 1 have been ou several The of this lecture will therefore occasionally subject evening's occasions consulted by mothers of young boys about he a review of the different forms of tumor of tho fourteen years of age, for a distinct aud ten- breaBt, more the in order swelling particularly benign tumors, derness of the mammary gland comiug on about the to prepare the way for the differential diagnosis be- of tween them and the forms of disease of the age puberty. malignant few acini are at the ends breast. Comparatively developed of the ducts and smaller tubes at this period. In out this a little more exhaus- studying subject Outside of the ducts and tubes we and the develop- than I had hitherto doue, I was struck with the tively ment of a hyaline connective-tissue stroma, having lack of unison in the of different writers on opinions parallel bundles of libres, which is quite a marked this There seems to exist an subject. imperfect feature; and this basement stroma is differ- of the of the various diseases of distinctly knowledge pathology ent from the counective-tissue stroma of the gland the breast, more the even particularly tumors, among proper itself. It is quite rich in nuclei, more or less the writers of the Iu over highest authority. going transparent, aud different in its nature from the ordin- the in out the of different work, sifting opiuions ary connective tissue which we get iu the stroma of authors, in them, aud then in a summarizing taking the mammary gland an interesting point to remem- view of the whole I think that 1 — geueral situation, because it has a the at conclusions which I not ber, again bearing upon develop- have arrived should have ment of certain morbid under other growths. arrived at any circumstances. The next in the is the We will at the of the and stage development develop- begin development glaud, ment of the acini, and this takes a sort of trace somewhat the earliest forms of place by briefly develop- a out into the ment of the the of full and budding process, growing surrounding gland, period maturity, connective tissue ; and here we get the the decline and of it iu advanced life. physiological gradual atrophy homologue of true adenoid tissue, that ¡a, a new devel- The as know, an mammary glaud is, you appendage opment of typical tissue, by a out of of I he skin as one writer has a sort of gland growing ; expressed it, little processes of at first solid, and later It as a epithelium, highly specialized sudoriparous gland. begins spaces which a true of the rete into the cutis containing represent gland growth. slight outgrowth Malpighii At the time of pregnancy this development of acini vera iu the weeks of fetal and at the early life, period takes place at an enormous rate. After lactation is of birth it haB formed a number of already radiating over the acini collapse, but they do not ; aud ducts with or some fifteen disappear pear club-shaped ends, to of course they remain there to be distended at in from the common at again thirty number, radiating point the next period of lactation. which the outgrowth has started from the surface. After the period of full maturity of the gland has If we the in the of study development embryo passed, we come to the period of decline, which, of mammals, we see some features iu the interesting course, becomes more marked at the menopause ; aud of which have a on what process development bearing we have there another important and con- wo have to about morbid later on. 1 have interesting say growths dition to study. We find then that the acini to here three of the of about oue month's begau embryos pig be absorbed and to disappear; and what we have finally An examination of the abdomen with a lens growth. left is merely an tube which generally ends shows a faint continuous line from the axilla elongated running in more or less of a club-shaped aud we to the on either side of the abdominal extremity, groin cavity, have connected with the end histológica! structures and, as the fetus grows, this line works up more nearly which show tho atrophied remains of exist- on to the front of the abdomen. The formation of the previously ing acini of the At this time also we often liud numerous or of the takes gland. udders, mammary glauds, a slight amount of desquamation of epithelium and place a of this of the as it by growth layer ectoderm, granular débris in the interior of the tubes, as if this is called, aud a of differentiation a thicken- by process period of metamorphosis of epithelium was disturbed at three or four of the line occurs. ing parts Finally, iu its process of and and was stimulated we liml that the line itself has and in its growth decay, disappeared, to a little greater activity at certain points than it had place we have a row of nipples. been before. I have said that at birth the glaud had a sort of As the structures of the breast and stellate or of a gland atrophy radiating appearance, bciug composed disappear, connective tissue aud adipose tissue come to series of ducts with or ends. Au pear- club-shaped take their aud we finally have a breast con- examination of them shows considerable with- place, activity taining merely the larger ducis, a small amount of fat in the tubes at the time of birth. There is a proliféra- and connective tissue, but little or no proper glaud 1 An Evening Lecture at the Harvard Medical School. tissue.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY OF MELBOURNE on June 22, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. I think that you will agree with me that there is a by Professor Porter iu the " Proceedings of the certain parallelism in the development of the breast, American Association," where the breasts Surgical • as I have sketched it, and in the development of the were much more largely developed, and where he suc- different types of tumor at different periods of life. ceeded in removing by amputation both the breasts In the first place, I have spoken of the condition of very successfully. The anatomical condition of dif- the mammary gland at birth, and later on at the period fuse hypertrophy of the breast seems to differ iu of puberty, the great development of the gland, the different individuals. In some cases it appears to be peri-acinous and peri-tubular growth of the hyaline con- simply an increase in the amount of glandular tissue. nective tissue, etc. ; and we sometimes find that develop- In other cases it seems to be an increase in certaiu ment occurring iu a precocious aud somewhat exuber- constituent parts of the mammary tissue; and iu the ant w;i\, ¡nul the condition which is known as infantile case of Dr. Porter, which was examined by Dr. hypertrophy illustrates that peculiar couditiou of the Whitney, there was an interstitial growth giving rise gland. I have here a photograph of a child with fully to that cystic type of breast disease which we shall developed breasts and quite well developed figure, speak of presently, so that there seems to be a certain whose age at the time the photograph was taken was amount of tumor formation iu such breasts. In the two years and seven months, a case kindly placed at second case to which I have just alluded there did my disposal by Dr. Marcy. The sexual instincts of not seem to be any lobular growths which indicated the child were Btrongly developed. Another unusual any such form of growth, but a general diffuse en- form of development of the mammary gland is a con- largement of the breast—gigantism, if we may say dition known as gynecomastia, that is, development of so, of the mammary gland. a female breast in the male. Williams represents such Now we will take up more characteristically tumor- a breast in a well-formed young roan, and Henry de- like growths of the gland, and attempt to trace the scribes the case of a man who had very well-formed analogy between them and the changes seen in the breasts, and who assisted his wife to suckle a family of mamma at the different stages of its development and eight children. decline. I shall Bpeak first of fibroma of the gland, I have here the photograph of such a case. This which comes in the early period of the life-history of man evidently exhibited himself as half man and the adult mammary glaud ; and then of the cysto- half woman. Ho has allowed the hair on one adenoma of the gland, which comes in the period of side of the body to grow and on one side of the lip. the full development of the acinous portion of the It is evident that he is a typical example of gyneco- glaud, the more strictly glandular structures; and mastia, having the ordinary figure of the man in finally, about the cystic degeneration of the gland, every respect except in regard to the right breast. which comes in the period of senile change and Another form of malformation is that known as decline. I n il \ 111:1 siiii, and all I have to do is to recall to you First, in regard to fibroma. If you remember, I the development of the milk line in the pig and in called your attention to the fact that at the age of the lower mammalia to show how it comes about that puberty there was a growth of hyaline tissue about this condition of polyinastia or multiple breast occurs the tubes and lobules of the gland. Fibroma of the in certain cases. In this diagram I have indicated the gland, according to Billroth, is developed from that line which you have seen, the milk line, and where the structure. These tumors appear iu early life shortly nipples would be likely to occur perhaps in the lower after the period of puberty. There are two formB of mammalia and possibly iu mail's earliest ancestors, as fibroma, the solid aud the cystic. In the solid forms, Williams has indicated in his monograph on the breast. where there are no cysts, the average- age is said to Cases of breasts upon the thigh and back, of super- be about twenty-three years, and in the cystic forms numerary nipples in these localities have been quoted, about twenty-six years. but it is probable that the majority of supernumerary I will speak first of the cystic, which is, perhaps, breasts develop themselves along this line; aud we the most common and most characteristic. I have see here in this case, which is an example not only of here a diagram of that growth stained with a double polymastia, but of diffuse hypertrophy, that we have stain of eo8Íne and hematoxylin. The epithelium is the development of supernumerary gland tissue along stained purple, aud the fibrous tissue pink; and we just that line, and if we could have lifted up that breast see in between these long slits, which are so charac- in the photograph a little bit, we should have found teristic of the cystic fibroma, or intra-canalicular pap- beneath it a supernumerary nipple. This patient illary fibroma as it is sometimes called, this hyaline came under my observation at the hospital a year or tissue. With the active growth of this tissue there is two ago, when she was at about the middle of her preg- a stretching and distortion of the ducts of the glands, nancy. The photograph was taken at that time. the acini having been but very imperfectly developed The second photograph was taken about the time of at that period of life, and these long narrow slits are confinement in the lying-in hospital. After the con- thus developed. We see but little glandular struct- finement had taken place the breasts diminished very ure in such tumors. These tumors reach about the greatly in size. Dr. Anthony, of Bradford, after- size of an egg or a little larger, are more encapsuled, wards took her through a second confinement, and and when excised do not, as a rule, recur. They are found renewed enlargement of the breasts and subse- generally single, but sometimes multiple. I saw yes- quent subsidence. In her second confinement she terday a young lady operated upon three years ago for was allowed to nurse the child, and tho breast secreted a tumor of this kind of the right breast, and find that an abundance of milk. she has another of the same character growing in the Diffuse hypertrophy is a condition which this pa- left breast. She is now about twenty-one years old. tient also serves to illustrate, but really a more typical Gross speaks of a solid fibroma of the breast, and I example waB that which I have represented in my presume he refers to the little hard lobular tumors, work on surgical pathology and which was published about the size of a walnut, which Sir Ashley Cooper

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY OF MELBOURNE on June 22, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. has described as " chronic mammary." We make a ing-down process we should have little hemorrhages section and we find none of the slits. We find a few which would cause discharge from some neighboring fragments of gland-tissue, and in the interstices between excretory duct. the gland structure dense fibrous tissue. This is a I pass by the lipoma, chondroma and osteoraas of comparatively harmless growth, does not become in- the gland as extremely rare forms of tumor, and flamed, increases to the size of a walnut and there tumors which have nothing in particular to do with romains. The patient experiences a little pain and the mammary gland, and come to the kind of tumor, tenderness at the period of the catamenia, but other- or more properly disease, which we find in the declin- wise has no trouble. Lately, at the hospital. I had the ing stage of the gland ; in that stage when the acini opportunity of examining such a tumor which had been become atrophied and are replaced by connective tis- twenty years in the breast of a woman who came for sue, and the tubes are somewhat dilated towards their another affection entirely, and she said she had ex- extreme ends into club-shaped dilatations, and are perienced no trouble from it whatever. lined with a somewhat thickened and desquamating We come next to a form of tumor which has to do layer of epithelium. Tho gland going through this more particularly with the gland structures of the process of atrophy, with substitution of connective breast ; and here we find a tumor growth more dis- tissue and fat for active gland structures, this distinctly in the middle period of life, the average age turbance of epithelium may easily become so altered being about forty-three. Here we find very distinctly in certain parts as to disturb the regular process of gland structures existing, and this is a section taken involution, and consequently constriction of the ducts from one of these growths kindly prepared by leads to the formation of cysts. Now these cysts Dr. Whitney and drawn by Mr. Kaula. You see may be either single, confined to one lobe of the gland these growths are somewhat polypoid or villous, and and growing to the size of a walnut, or they may they have been called villous papilloma by some permeate the whole of the gland. This is cystic authors, and cystic adenoma by others. They are full degeneration, as it is sometimes called a condition — of little spaces more like acini than tubes, though which exists probably in a slight degree in the sometimes they become more oval aud elongated like majority of declining breats. Some pathologists call tubes and are lined with a layer of epithelium. It is this condition, of which I have an example here, evident that these tumors grow from small acini and chronic mastitis with retention cysts. This is a breast very small ducts of the gland. They develop in dif- split open to show the whole interior of the gland ; ferent ways, according to different authors. Bill- aud you see here the whitish mammary tissue and roth suggests that there is a very active growth of these little cysts full of greenish material, and some epithelium, and quite a number of acini develop in again quite large, and as in this case so extensive that which the epithelium afterwards breaks down and the whole breast had to be removed on account of the leaves cysts of considerable size. The Btroma of the complete degeneration which had taken place. Some gland takes a comparatively small part in the develop- authors think this is a form of cysto-adenoma but there ment of the tumor ; and so we see little of the connec- is no development of the glandular structures, as it tive tissue as compared with the great mass we see in belongs to the period when the parenchyma of the the fibroma of the gland. Sometimes these cysts glaud is atrophied and in a quiescent state, and when develop to a very groat size ; aud here is one of the the gland itself is in a state of involution ; and there- most marked types, which was removed at the hospi- fore it is to be looked upon rather as a degenerative tal a few days ago, and we Bee one of these villous process than an actively developing one. These cysts tumors developing in it. occur at about the time that malignant disease devel- Gross has almost deuied that there is such a thing ops, and consequently they are the subjects of great as true adenoma of the gland. He is very strict in solicitude to the patients -suffering from them ; but his definition of what adenoma should be. He has the characteristic symptom is the presence of a largo seen, he says, but two examples of it himself, and has number of little pea-like bodies diffused over the gland, only eighteen examples of pure adenoma on record. sometimes in one breast, and sometimes in both breasts, I think that he has attempted to isolate too com- accompanied with considerable pain, caused by a pletely the gland structure from the other structures hyperesthesia of tho nervous filaments going to them. of the breast. You see that iu so complicated an I should like to say a word about the treatment of organ as the breast, when one part grows the other these cysts. When there is a single cyst a puncture must grow to certain extent, aud we get complicating will sometimes suffice for a cure, as the cyst will col- and confusing pictures somewhat difficult to Interpret; lapse and nover fill again ; but where the disease is but if we hold fast to the point of origin of the growth more extensive and involving the whole of the gland, we do not have that difficulty. If we hold to the then it is perhaps necessary to remove the whole or acinus growth in the cystic adenomas, we shall have portions of the gland. If the cysts do not enlarge, an ample explanation of the peculiar papillary charac- they may be allowed to remain, as they will probably saved ter of the growth, which is not a papilloma any more give no trouble and many such a breast can be than its surroundings oblige it to be, and therefore we from the knife if a correct diagnosis is made. Why should properly classify this as a true form of ade- should these cysts have this peculiar color? The noma, modified of course to adapt itself to the structure walls of the cyat being in a state of glandular irri- in which it grows. This form of tumor appears at tation, the epithelium breaking down, tho vessels be- the time when the acini are in a most active stage of come thrombosed through hyperemia or perhaps con- ... extravasations of development, that is, in the forties. It is a softer striction of their lumeu, and little tumor than the fibroma, aud does not grow much blood take place, and we have heraatoidin crystals larger. One of the characteristics is a saueous dis- and granules of fat aud broken-down tissue that give charge from the nipple. We can understand how them this peculiar appearance. to be that would occur in vascular growths ; by the break- An affection which is likely mistaken for

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY OF MELBOURNE on June 22, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. this is oue known as mastodyuia or neuralgia of the the ilium. Breaking-down carciuomatous tissue could breast. That sometimes accompanies this cystic de- be dug out with the finger. This was a fruitful source generation of the breast, and sometimes is entirely for the sepsis. independent of it. I think we see it at times with a The other (Case IV) died from shock. She was certain amount of hyperemia, and perhaps a tempo- very much exhausted from long-continued loss of blood, rary enlargement of the breast without any actual by a long and difficult operation, and by a mortal dread structural change. These caBes are extremely hard to of the operation. She took ether very poorly. Several manage, the patients becoming hypochondriacal ; but the times during the operation the pulse and respiration pain is usually not accompanied by any serious disease. stopped, and when I had finished she was cold, and I I have not said anything of chronic mastitis of the supposed she was dead. Four of us worked over her breast. I have left that to the last not to have it for two hours before she began to rally at all, but confused with any of the other affections mentioned. spite of all we could do she died in thirty-six hours. We may have an inflammation of the breast, and a In the two celiotomies for tubercular disease of the chronic as well as an acute one. I shall say nothing pelvic organs, death was caused by sepsiB. One oc- about the acute inflammations. The chronic form is curred at the St. Elizabeth's Hospital (Case 1), the one which may occur aud be accompanied by a con- other at the Carney Hospital (Case II). In both siderable growth of connective tissue such as we cases it is presumable that they became infected by the have in the cystic degeneration. In chronic mastitis pus that escaped into the peritoneal cavity from the we find great growth of the interstitial tissue and ruptured tube. In Case 1 gauze drainage was used. destructiou of the glandular structures. Billroth rep- For suture material within the abdominal cavity, resents, and Williams copies from him, a form of catgut was used as much as possible. By using an shrinking mastitis which has all the appearance of absorbable material for ligatures, we avoid the trouble atrophying scirrhus. Occasionally we do have a which bo often begins weeks or months after silk has chronic inflammatory process of the breast going on been used in the abdominal cavity, and continues until to destruction of the breast. It may occur in early as the silk is gotten rid of through the line of incision, well as late life. I remember a nursery maid who bladder or intestines. I have had it escape by all came to me twenty years ago with a lump in the these routes. Iu one case the intestine became adher- breast. I removed it, and found no trace of malig- ent to the knot of silk used in tying off the left tube nant disease. I made the diagnosis of chronic mas- and ovary. Long-continued suppuration, with severe titis. Presently she appeared with a similar lump pain, necessitated a second celiotoray. It was found in the other breast and I explained to her that she had that the silk knot had worked its way into the intes- not anything which it was necessary to remove. tine, leaving a lonif fistulous track. Nevertheless, she had it burned out afterwardB by Resection of the diseased and perforated intestine a cauBtic process. She is still, so far as I know, in was successfully done by Dr. S. J. Mixter. Now that robust health. I think such cases are not very com- small aud medium-sized catgut can be made perfectly mon, but they are to be taken into account in making sterile without impairing its strength, there is no a diagnosis of malignant disease of the breast. excuse for using silk. I do not think it is safe to trust 1 have not time to speak of tuberculosis or cold those who make a business of sterilizing suture abscess of the breast. I think I have said enough to material. If you do trust suture material sterilized give you perhaps a little more intelligent idea of by other«, you will sooner or later certainly come to the origin of benign tumors of the breast and of the grief. Iu the sterilization of suture material, eye- different types which we may expect to find at differ- servants should never be employed. ent periods of the life history of that organ. I have found two reliable methods for making catgut sterile. Catgut prepared by either of these methods is perfectly sterile. Both Dr. J. H. Wright Articles and Dr. E. A. Darling of the Harvard Medical Original School, have examined catgut made sterile by these methods, and have it free from bacteria. DEDUCTIONS FROM HOSPITAL WORK IN AB- pronounced I have never had follow the use DOMINAL SURGERY, WITH A REPORT OF suppuration of catgut FORTY-FIVE CASES.1 thus prepared. Iu both the is soaked in the ether BY F. W. M.D., processes gut for JOHNSON, several It is then cut Gynecologist at Carney, St. Elizabeth's and Woman's Charity Club days. into the desired length, Hospitals. each length being thoroughly stretched (the stretching Tim following forty-five abdominal operations were prevents kinking and twisting, which is so very annoy- done during the spring of 1896, at the Woman's ing). The gut is then soaked twenty-four hours in Charity Club, St. Elizabeth's and Carney Hospitals. absolute alcohol, to take out as much of the water as It with a There were nine hysterectomies. possible. is then covered solution of bicro- of in absolute alcohol Of the forty-five, four died ; two supra- mato potassium (15 grains to the following aud remains iu this twelve pubic hysterectomy for carcinoma, and two following pint), hours. celiotomy for tubercular disease of the tubes and In Process No. 1 each length is coiled up, done up iu waxed and in an ovaries. The two deaths following hysterectomy were paper, put envelope which is at the Woman's Charity Club Hospital. sealed. The sealed envelopes are put in a dry oven, and baked for one hour at a of 100° C. One (Case II) died of sepsis. The operation was a temperature This removes all the long one, and the patient was much exhausted by it. moisture, and thus prevents On the right side the disease had extended outside the further beating, making the gut brittle. On the fol- the sealed are baked three uterus, infiltrating the right broad ligament as far as lowing day envelopes hours at a of 140° C. The íb, now 1 Read before the Obstetrical Section of the Suffolk District Medi- temperature gut ready cal Society, November 4, 1896. for use. The envelopes are kept in a glass jar.