How much a rapidly arising infiltration of the lymphatic glands may hasten the course, and how much an operation before the invasion of the lymphatic glands, will delay the fatal issue, may be learned from the following resume, from A. von Winiwarter. After operations, with exist ing lymphatic invasions, and after extirpation of these, the average time from the last operation to death, from recurrence, is thirteen months, the total duration of the disease twenty-nine months. In cases in which the operation was performed before appreciable involvement of the lymphatic glands the patients lived, on an average, after the operation, twenty-two months, and the total duration of the disease was fifty months.
By metastatic tumors we understand those in which continuity of the dis ease cannot be thought of. When skin, muscles, ribs, pleura, anterior surface of the pericardium and heart, and the diaphragm are affected on the same side as that upon which the mammary carcinoma has its seat, we consider this a continuous disease. Whether it can also be considered that the affection may directly spread through the lymphatic vessels of the diaphragm to the liver, and through the posterior mediastinum to the vertebral column, remains uncertain. Of the nodules which are found after death in the substance of the lungs, liver and kidneys, we believe, according to our present views as already set forth, that they are the result of emboli, i.e., carcinoma cells get into the veins, and are then carried (with or without being surrounded by blood-coagulum) into the right heart, and thence to the lungs. If the elements are small enough to pass through the capillaries of the lungs, they go to the left heart and thence into the aortic system, in which they here and there remain adher ent. If, on account of their size, the carcinomatous particles cannot pass through the pulmonary capillaries, they attain further growth here, penetrate into the pulmonary veins, thence into the left heart, and so into the aortic system. If this theory be correct, the frequency and distribu tion, with all their contingencies, must be analogous to pytemic metas tases. This is supported by the fact that the embolic theory of carcinoma and (sarcoma) metastases is powerfully supported by it.
It may now perhaps be very possible that in the primary carcinoma some particles may grow into the veins and thence be carried away. But this never seems to be the case, for in all the cases known to me, the lymphatic glands were always affected; whether always before the inter nal metastases is certainly hard to prove, as the latter cannot always be diagnosticated with certainty. This objection I consider excluded in the
two cases reported by Volkmann, in which, in carcinoma of the mamma, metastasis occurred once in the liver, once in the sacrum and once in the lower part of the vertebral column, without the axillary glands being affected. As regards the time elapsing from the beginning of carcinoma of the mamma to the invasion of the lymphatic glands, until metastases occur, our knowledge is very deficient. It seems that there are great variations in this respect. Those cases on which we operate under entirely favorable circumstances, but in which the patients already have internal metastases, as is shown by the autopsy when the patients die shortly after the operation, are unfortunately not very infrequent. Of thirty-four who died after operation, five already had extensive internal metastases. The primary tumors were first noticed, five, six, seven (twice), and nine months before the operation; in three cases the metastatic nodules were situated in the liver, in one case on the pleura, in one case in the lungs. I remember several cases in which tumors of the liver could be felt a few weeks after an operation which had a favorable course. In other cases it is a very long time before internal metastases appear; but possibly these may occasionally grow very slowly, and if they are small, may give no trouble for a long time. It is well known that the lungs and liver may be completely studded with small neoplasms before their function is so interfered with as to become fatal.
As regards the frequency of the situation of these metastases, there is a deficiency on this point in the histories of the great number of reports of autopsies of persons who have died of carcinoma of the mamma. Such a collection can be productive of good results only when made from the reports of autopsies performed in very large hospitals, and especially of cancer-hospitals. What data we have are based upon too small a num ber. Birkett has collected thirty-seven cases in Guy's hospital. This collection was made at a time when very different views prevailed as to metastases, and such data are therefore scarcely fitted for our purpose. Still, some principal points are very distinctly brought out. Several metastatic tumors were found as follows: in the liver, 14 times; the lungs, the bones, 6; the kidneys, 5; the ovaries, 4; the uterus, 4; the cere bral meninges, 2; the pericardium, 2.