The infiltrated forms, by far the most frequent (carcinoma simplex, tubular form,) run an exceedingly different course. In the worst cases the course is but little different from that in those described above, except that it is more slow. It affects well-nourished women between thirty and forty years of age. It is an infiltrated, at first slow for a few months, then an ever-rapidly spreading induration, and soon the larger part of the gland is affected; after 6 to 8 months, swelling of the axillary glands, and soon swelling of the supra-clavicular glands set in. There is compression of the axillary vein, and indurated oedema preceded by neuralgic pains in the arm. There is ulceration of the skin after perhaps the lapse of 1 to 4 years. State of nutrition is good for a long time. There are metas tases in the pleura of the affected side, and also of the liver, of the bones, not infrequently of the vertebraa, and fearful pains, from which death finally frees the patient two or at most three years after the beginning of the malady. In other cases there is early adherence with the skin, and de velopment of nodules in the skin, especially after the first operation. Radi ating extension of these nodules around the cicatrix squirrhe tegumentaire, tuberenleux, repeated operations, without good results—such is the history. Axillary glands are hard, but not very large. The local extension constantly increases. The nodules in the skin soon ulcerate and become confluent. The skin over the whole anterior portion of the thorax is studded with nodules, and becomes immovable. A sim filar process often begins on the opposite side; not infrequently hyperaemia in streaks (squirrhe, rayonneux, ramonneux—Velpeau) precedes the for mation of nodules The whole thorax becomes surrounded by indurated, partly ulcerated skin. (Cancer erg cuirasse—Velpeau). Emaciation, marasmus, late and not extensive internal metastases follow and death occurs from marasmus, loss of fluids (systemic drain), repeated hemor rhages. The duration is 3 to G to 8 years and longer.
All cases of colloid cancer take a similar course. In the case men tioned by Dontrelepont the duration was 13 years.
The mildest forms of infiltrated carcinoma pass from the form of the atrophying, cicatrizing carcinoma, to the scirrhus. How long the last may exist without causing death cannot be said. I know of cases in which old women bore such indurations for more than twenty years, and finally died of another disease. The nodules ulcerated several times; the ulcerations were checked by fomentations of lead-water; at times some necrotic tissue was thrown off, and the hole was closed again. In the axillary space superficial lymphatic glands were slightly swollen at times but were very hard; then they shrank without breaking, leaving a re tracted. slightly hard scar. As I neither received these cases at the clinic, nor operated on them in private practice, only a few cases appear in my yearly reports.
Detailed statistical data as to the most important periods of the course of carcinoma may be found in Volkmann (Beitthge zur ehirurg. Leipzig, 1875, p. 319) and in the previously mentioned book of Al. v. Winiwarter.
The outer side of the breast is affected in by far the greatest number of cases (in 54.4 per cent. of all cases—von Winiwarter).
The axillary and infra-clavicular glands are always affected before the supra-clavicular. The infection travels by degrees from below upwards (Volkmann), though deeply-lying glands arc not infrequently affected be fore superficial ones (von Winiwarter). The infection of the axillary glands follows in the course of 14 to 18 months after the beginning of the mammary affection. For single cases this does not answer, as the ex
tremes of the intervals are very great. In one case the axillary glands were affected within one month, in one case not until seven years after the beginning of the tumor in the mammary gland (von Winiwarter). It is true the axillary glands are affected somewhat earlier when the car cinoma is situated on the outer upper part than when on the inner part, though the difference is not so great as one would a priori suppose (von Winiwarter).
Volkmann has observed cases in which, on one mamma being affected, the axillary glands on both sides were invaded; and also cases in which when the internal part of the mamma, lying nearest to the sternum, was affected, only the axillary glands of the opposite side were invaded. There is no doubt, though it is very rare, that purely inflammatory non-carci nomatous swelling of the axillary glands does take place in carcinoma of the mamma, which disappears after operation. Von Winiwarter cites an authentic case of this kind.
After extirpation of the mamma and of the axillary glands it not infre quently happens that the swelling of the supra-clavicular glands, which has escaped observation before the operation and become perceptible soon afterwards, ceases for a long time, and even almost entirely disappears by fatty degeneration and contraction.
Besides the cases mentioned by Winiwarter, the following case observed by me a short time ago belongs here: Two years ago I operated on a rapidly growing carcinoma of the right mamma in an otherwise healthy woman of about thirty years of age; the moderately enlarged glands were extirpated with the mamma. There was rapid healing of the wound. Six weeks after the operation, the patient returned with a supra-clavicular tumor of the lymphatic gland, as large as the yolk of a hen's egg. I gave an unfavorable prog nosis. A short time ago I saw the patient; she had grown markedly in weight and had a blooming appearance. The tumor over the right cla vicle existed as before, and gave her no trouble. Perhaps the following case is more remarkable.
Von Pitha operated in October, 1871, on a woman about sixty-four years old, for carcinoma of the right breast. The whole left mamma and large masses of axillary glands were also removed; healing occurred rapidly. The very well-nourished woman, who lived in the best circumstances, felt excellent. Soon, however, a new tumor appeared deep in the axillary space and under the clavicle; this, without becoming very large, became constantly harder, and caused fearful neuralgic pains in the left arm, which gradually swelled, and attained such enormous proportions as to resemble elephantiasis, and this was only slightly improved by bandaging. The patient consulted all the surgeons whom she could get at. Not one wished to incur the responsibility of a new operation, which could only consist in a disarticulation of the humerus; they were much less inclined to such an extreme operation, as the woman was fat and healthy other wise, and would probably be entirely well if she were not tormented, especially at night, by these pains in her arm; but as she tolerated mor phine and chloral well, she lived in fair comfort, until, in the summer of 1877, rhagades and ulcerations appeared in the axilla; this caused an arterial hemorrhage on November 2, 1877, to which the patient suc cumbed. The carcinoma of the lymphatics in this case, had remained quiescent for five years. Unfortunately no autopsy could be made.