Professor C. v. Braun brought on premature labor. On June 12th, a seventh months old child was born, which died soon after birth, and showed nothing abnormal. The patient was continually febrile to a mod erate degree, began to cough, threw off much mucous sputum, became entirely anorexia], and died of marasmus on July 12th, one month after labor Unfortunately I was not permitted to make the autopsy; I could only obtain permission to remove some pieces from the mammte. (The right mamma had meanwhile reached the same size and condition as the left.) The tissue was light whitish-yellow in color, was soft, and tena cious; a milky juice could be expressed from it. Microscopic examination showed that on both sides there was a granulation sarcoma (Gliosarcoma, Virchow's small-celled, round-celled sarcoma.) (Fig. 17.) I have now to add the following points. A true secretion of milk did not appear after confinement. The " milky" fluid mentioned above, contained no milk elements, but only small lymphoid cells. But what was very striking to me, and which was always confirmed on repeated exami nations, was the fact that there was no trace of glandular elements in the many wedge-shaped pieces cut out even from the depths of the tumors. which, taken together, were larger than at first. At all events, we did not have to deal with an aberrative formative activity of the epithelium of the glands. Very similar was the second case observed by me.
Mrs. Fanny J., 36 years old, working woman, had had several chil dren. She said that five weeks before she came to the clinic, on June 21, 1875, up to which time she had been perfectly healthy, and in the eighth month of her pregnancy, there suddenly appeared a feeling of ten sion at the circumference of both breasts (as she said the result of catch ing cold !) From this time on there was rapid growth and hardening of both breasts. Seven days previously she gave birth, without any material loss of blood, to a healthy child, after the induction of premature labor by C. v. Braun. On admission the patient was very much emaciated and very pale. The breasts were larger than a child's head, hemisphe rical, firm, covered by tense, glistening skin, colored bluish by numerous veins, and, on account of the cutaneous tension but little movable on the subjacent parts. The tumors were firm, and in only a few places elastic; no colostrum could be expressed from the nipples. Axillary glands not perceptible. Compression of both breasts by bandages. Patient became weaker daily, vomited whatever food she took, and died on June 28. The total duration of the disease was, therefore, only six weeks. To the above report I will add that the autopsy showed metastatic white nodules in the thyroid gland, pericardium, liver, mesentery and kidneys. The breasts were surrounded by a lobulated, mostly reddish, soft mass, show ing a milk-white fluid on its cut surface, and were bound fast to the fascia of the pectoralis major muscle, by means of condensed, infiltrated cellu lar tissue. I unfortunately neglected to make notes of the microscopic
condition, but I can state the following with certainty. From the analogy with the first case I considered that this tumor was also sarcoma, especially since there were no tumors of the axillary glands. But I have since cor rected this diagnosis on the hospital book, and have designated the case as carcinoma, because I found, besides the very abundant lymphoid in filtration of the connective tissue, by which the interstitial tissue assumed the character of lympho-sarcoma, here and there indisputable epithelial cell cylinders and gland-like formations, which had the character of ordi nary carcinoma. It may, therefore, have been a combination of carcinoma and sarcoma. I must add that, at that time, the occurrence of large celled, alveolar sarcoma in the mamma was not known to me, and that unfortunately I could not find the preparation recently in order to make another examination of it.
The similarity of these two cases is striking. Both women in the be ginning of the thirties, both had already borne several children, and with out ever having had any trouble. In both the tumors developed rapidly in the fifth and seventh month of pregnancy. In neither was there a regular secretion of milk, after the induction of premature labor. Nor can we say of the tumors, which had more the character of sarcoma than carcinoma, that a formative aberration of the epithelial glandular ele ments was the most important factor. It has already been said that true hypertrophy of the mamma can in no way be considered as having a defi nite relation to pregnancy or lactation, without straining the facts; more probably it is connected with the development of puberty.
Luecke,' Volkmann' and Hermann Klotz,' from some of their observa tions, are especially inclined to concede to pregnancy a prominent influence in the development of carcinomas of the mamma. Al. von Winiwarter also supports this view by two cases observed in my clinic, in which a nodule developed in the breast during pregnancy (once in the cicatrix of an ab scess), which subsequently became carcinoma. These cases, as almost all of those reported by Volkmann and H. Klotz, are not identical with those which I report above. True enough in two of Volkmann's cases both mammas were successively attacked, though, as in my cases, there was a considerable interval of time, and the infiltration had the character of carcinoma simplex with rapid extension to the skin; in the other cases only one breast was affected, and the course was probably more rapid, though not different from the course of the other cases which did not coincide with pregnancy or lactation. In most of the cases of this kind, the carcinoma appeared early (in the twenty-sixth to the thirtieth year), and later than this in only a few cases.