DIFFERENTIAL DIAGNOSIS AND PROGNOSIS OF TUMORS OF THE MAMMARY GLANDS.
As in dis ease of other parts of the body, so here the knowledge of the prepondera tingly frequent occurrence of this or that tumor in this or that period of life, and further the age, size, movability, rapidity of growth of the tumor, with especial reference to the affected organ, guides us. What we have to say here on this subject will be only to give the beginner a few of the main points; the details are found in the section on anatomy and clinical course, in which the symptomatology is also included.
When a tumor of firm consistency develops in the breast of a woman 35 years old, and continues to grow, it is probably carcinoma. This is not to be doubted when the tumor is immovable in the gland substance, when the axillary glands swell and become hard, when the tumor is adherent to the skin and ulcerates. When the diagnosis of cancer has once been made in such a case, the prognosis is also thereby given, as a rule. Still, there may be many modifications in regard to this, especially as concerns the more rapid or slower progress of the growth of the tumor. If the tumor has grown comparatively quickly up to the time of inspec tion by the physician, it will usually keep on growing rapidly; if its course up to this time has been slow, it will probably continue so, though there are exceptional cases in which, after years of slow growth and occasional cessations, a rapid growth is suddenly inaugurated without known calms. If a cancerous tumor undergoes rapid softening, if it becomes partially fluctuating and then breaks, it usually goes forward rapidly with the other subsequent phenomena. If rapidly and successively the largest part of the gland, or the whole of it, becomes infiltrated, the course as regards general infection is usually more rapid, also when the supra clavicular glands, besides the axillary glands, are also rapidly affected; also those cases in which the skin is quickly affected and studded with innumerable cancerous nodules, as well as those in which both breasts are rapidly affected in succession or at the same time, are to be prognosti cated very unfavorably. In all cases of already advanced carcinoma of
the breast the liver is to be examined. The most favorable cases are always those of ecirrhus which come on in old age; their course is very slow, and they infect very late or never.
There are a number of accessory symptoms of mammary carcinoma. Among these is retraction of the nipple; it occurs when the carcinoma originates in the neighborhood of the nipple, and the nipple region is drawn in by interstitial cicatrization. In other cases this symptom is also apparent when the skin immediately surrounding the nipple is affected and bulges forward, so that it more or less overtops the nipple. When the infiltrated nodules lie more remotely from the nipple the part of the skin which is adherent to the carcinoma becomes cicatricially retracted in case a process of shrinking occurs in the neoplasm. Pains are to be considered as accessory, but often absent, symptoms of mammary affection. They are often present at the beginning of the disease, and appear again at the time of softening and ulceration; many run their course with very great pains, and others are entirely painless. Of very little value are visible, dilated subcutaneous venous tracts over the tumor; they may be present in every tumor of the breast which compresses the deeply situated veins. So, too, I cannot hold that the escape of serous, brownish reddish fluid from the nipple is characteristic of carcinoma, though it is often present in this disease; it occurs also in other tumors of the breast and without the presence of any tumor. Of comparatively little significance, too, is the appearance of the patients; at the beginning they generally seem entirely healthy, and have none of the specific functional troubles of carcinoma; then towards the end of the disease the cachectie appearance comes on. It may depend upon different circumstances: cancer of the liver, lungs and pleura with exudation, hemorrhage, ichorous discharge and the septic fever connected with it.