A diagnostic error in regard to carcinoma of the female breast can only occur after long observation when we take a deeply situated cyst for carcinoma, or the appearance of a carcinomatous tumor is simulated by the confluence of several smaller foci in chronic mastitis (which are gene rally accompanied by marked pains). It is better to operate in such doubtful cases than to allow the tumor, which may be carcinoma, to con tinue growing.
As to the course in individual cases, we have already stated it. Even with great experience, it is very difficult to give a certain prognosis, only in months, as to the time when these carcinomatous patients will be re lieved from their sufferings. The power of resistance is often very un pleasantly great, especially in those cases in which the digestive tract, the liver and respiratory organs remain unaffected. But then, rapidly arising pleuritic exudations or repeated arterial hemorrhages sometimes end life with unexpected rapidity.
Swellings and indurations of the breasts before puberty are almost always of an inflammatory nature. Only medullary cancer (medullary sarcoma) has been certainly observed at this early age, and so seldom that these cases can scarcely be considered as curiosities for diagnosis.
From the time of puberty up to the 30th and 35th year and later, roundish, lobulated, movable, usually painless tumors, as a rule of slow growth, are developed in the mammary gland. These may be chronic inflammatory foci; suspicion is so much the greater as regards this if there has been a previous traumatism, or when such nodules remain after pregnancy and lactation. The course will soon decide. The product of a chronic inflammation is either gradually dissipated, or softens and suppurates, but never grows continuously. If such nodules remain
stabile and hard for months and years, if they are roughly lobular, and later, perhaps only during the menstrual period, become slightly turges cent and moderately painful, they are benign fibromas, which often remain stabile.
If the tumors grow slowly, but continuously, they are adenomas, adenoid sarcomas, or cysto-sarcomas. These differences are not of very great significance as regards prognosis. It is between the ages of 25 and 35 that we find most frequently perfect cysto-sarcomas, not seldom of enormous size, probably also ulcerating and connected with swelling of the lymphatic glands. Though it is not very frequent, we must be pre pared to find recurrence in adenoid sarcoma and cysto-sarooma. They should always be excised early.
A very rapidly growing, soft tumor of the breast (at first to be con founded with abscess) in young girls and women, is most usually a medullary sarcoma, and is of bad prognosis; in these cases the disease may prove fatal in six or eight months from internal metastases.
Cysts are easily diagnosticated if they are large enough and are super ficial; otherwise not. If they contain no tumor tissue the prognosis is favorable. Deeply situated small cysts are not always to be differentiated from other tumors.
Bilateral diffuse hypertrophy occurs almost solely in young girls at the time of the development of puberty. Epithelial carcinoma of the skin is said to have been seen radiating from the nipple; from the cases which I have found in literature I do not think them beyond doubt. I have had no experience with such carcinomas.