I have never been able to show that the sweat glands, hair follicles and hair glands take part in the carcinomatous growth from the mamma to the cutis, though I have given special attention to this point. Doutre lepont's observation, according to which the epithelium of the sweat gland, in his case of colloid carcinoma of the breast, had an important part in the formation of cutaneous nodules, thus far, so far as I know, stands alone. By the extension of the carcinoma into the deeper parts, the periosteum of the ribs, the ribs themselves, and the pleura costalis and pulmonalis are involved, usually by the formation of nodules, which gradually lead to firm fatty infiltration and shapeless cicatricial formations, if the un happy women live long enough. Even these parts of the carcinoma (it occurs only in infiltrated, primarily tubular carcinoma) seldom show a distinct epithelial structure; I have been able to recognize the structure of the primary mammary carcinoma at time3 in the tissue of the ribs, as well as in metastatically affected vertebrae, the humerus and the femur. The same is true of metastatic carcinoma of the lungs and liver. The a priori, according to our present views, almost only possible theory, that these carcinomas proceed from the primary carcinomas by emboli corn cells, I am not in a position to uphold from observations.
As a rule we find tissue, similar to that in the primary carcinoma, only in the lymphatic glands of the axilla, which have become infected from the cancer of the breast. As there are often large portions of healthy ap pearing tissue, so far as can be judged by palpation and by the unaided eye, lying between the primary carcinoma and the affected lymphatic glands, infection of the affected spots can only have taken place through the lymphatic vessels or the veins. There certainly is seldom any proof that the carcinoma cells have a predilection for the lymphatics (Langhaus), though they could break into the thin-walled lymphatic tracts from the tissue in so many places that anatomical proof of this is scarcely neces sary. I have repeatedly seen the lymphatic trunks of the pleura and dia phragm completely filled with carcinoma cells.
I will forbear giving further details of observations on these difficult questions, and will only repeat my opinion, that I consider it certainly in the highest degree probable, in the present state of our ideas, that the con tinued as well as the interrupted extension of carcinoma is brought about by misplacement of corpuscular elements, but that we are not yet in the position to prove this anatomically for all cases. I may add that I might claim a like power of infection for the corpuscular elements of the small celled infiltration in carcinoma, according to which, carried to other places, they have the power of setting up chronic inflammatory processes resulting in induration and ulceration, and this, too, without bearing epithelial elements with them. Finally, I would again repeat that the
course mentioned is especially peculiar to mammary carcinoma; I have sem nodular coronary extensions in the form described in the same way in sar coma of the skin, but never in carcinoma (epithelial) of the skin, in which the continuous extension, as well as the infection of the lymphatic glands, as also the few cases of metastases, appear to be absolutely de pendent upon the epithelial growth, their direction of growth, and their misplacement.
2. Clinical Course qf Cancer of the Breast.—There are cases of carci noma of the breast which, from the beginning of the first nodule up to the time of death from internal metastases, last only six months; and other cases in which women carry carcinomatous nodules in the breast for more than twenty years without being greatly troubled by them. To make from these extremes exact types for different categories is as difficult as it is to separate different kinds of carcinoma of the breast with anatomical exactness from one another. If, however, we try to accommodate the clin ical course to the anatomical classifications given above, we can only do so by every reservation of transition and combination. The large and soft nodular (usually acinous) carcinomas have the most rapid course; in the majority of cases they occur in young women (from 35 to 40 years of age), though exceptionally there is a rapid course in older women. I will de cribe the following case, which I personally observed, as an example of such exception: In a previously healthy woman, 55 years old, several soft nodules formed in the right mamma, without known cause; she came to me at the Zurich clinic, eight months after the beginning of the trouble; one nodule had broken down and assumed a crater-like form (Fig. 51 is a picture of this woman); the whole right breast had degenerated into a large, nodular tumor; the axillary glands were swollen, though movable. Operation. After fourteen days, healing no longer progressed favorably; marasmus, pain in the region of the liver, dyspnoaa without fever, and pleuritic exudation on both sides, recognized by percussion, set in. Death four weeks after operation. Both lungs and the liver studded with many tolerably large, soft, carcinoma nodules. Duration of the disease (which in this case was probably not changed in its course by the operation), nine months.