PROLIFERATING CYSTO-SARCOMA.
Very striking in their external configuration are the proliferating cysto-sarcomata of the mamma. They have long been known and de scribed, though designated by many different names. The name " cysto sarcoma" with the addition proliferum phyllodes, was introduced by Johannes Muller, and has been used by German anatomists and surgeons since that time. Virchow has proposed the term " intra-canalicular myxoma." In England the designations, sero-cystic sarcoma (Brodie), cellulose hydatids, (Cooper), glandular proliferous cysts (Paget), cysts containing solid growths, some with fluid, some without (Birkett), are used. Velpeau gives these cases many different titles, usually " tumeurs adenoides," then " cysts with thick walls," " encephaloids with cysts," etc.
The not infrequently extensive tumors have large nodules, are encap sulated and of very different consistency. When they are out through, a great deal of serum and mucus usually escape. The cut surface is partly of a clear, pale reddish color, partly white, the tissue seeming yellow in places, oedematous (somewhat like nasal polypi), here and there studded with small extravasations, in other places tough and fibrous. The most striking thing on the cut surface is a more or less large number of irregu lar hollow spaces, filled with a thin mucus, and into which project leaf like (cysto-sarcoma phyllodes, Muller), or polypus-like growths, which more or less fill the hollow spaces. These growths are seen to rise from the hollow spaces, emptied of mucus, above the cut surface, so that they have so much more the appearance of growing from the fissure-cyst spaces. Besides, we also find a mass of large-branched fissure-cysts such as are described in the fibromata (Figs. 13 and 14); seldom are there simple round cysts, and more seldom the presence of white globules (epithelial pearls) in the cysts. The older anatomists have unhesitatingly assumed that cysts everywhere arise from exudation, and that new growths take place from their walls and in the cyst-spaces; they could with diffi culty rid themselves of the parasitic nature of new growths. If it be con ceded that the growths arise from a fibrinous, usually organized and vascular exudation from the blood, we still find no relation to the surface from which the new. growths have arisen; an exudation which leads to the formation of ouch a cysto-sarcoma may, according to former views, just as well arise in muscle, bone, brain or anywhere else. According to the view of our predecessors as to the soil in which they developed, they have no further relation than that they draw blood and nourishment from there. The idea that the tumors are only a form of degeneration of tissue was at first very slowly developed, and has only been fully accepted among all anatomists and surgeons during the last ten years. Since on this ac count we need not by any means give up a general knowledge of tumors, still, the development of tumors in each separate organ demands especial study. One of the greatest services rendered by Virchow is that he rec ognized and filled this need.
In the form which we have described, proliferating cysto-sarcoma can only occur in the mamma; it always includes glandular elements of the mamma. The fissure-cysts are the compressed excretory ducts of the lobules, lengthened, displaced, then again distended with fluid. The terminal vesicles are pressed together, lose their round form and also become fissure-cysts.
How the above-mentioned peculiar forms arise is very easily under stood if we make a fine section of an apparent solid part of such a tumor, but which . contains a number of fissure-cysts, and examine it with the magnifying glass or with very low power. At a, in Fig. 21, the termina
tion of an acinus is clearly seen; nothing of the gland-bulbs is seen; they are pressed into narrow canals. In this preparation there is nothing of the virginal mammary gland, but of the mamma of a woman who has borne and nursed several children; the spaces which now appear as narrow canals, not fused together on account of their epithelial covering, were formerly round gland-bulbs (acini) filled with milk. The narrow and during lactation almost shrunken connective-tissue sheath walls between the bulbs have now grown to a colossal size, and as they form the floor for the glandular epithelium the epithelial surface must also grow. It is perhaps very much as in enormous enlargement of the cutaneous papilhe; with their growth also grows the epithelial surface. Therein appears to me to be the proof that the acini can have no true membrane propria, which, unconnected with the connective-tissue floor, is only loosely at tached to it; if this be the case, it and the epithelial surface do not need to enlarge, since the connective tissue itself enlarges. But with this con ception, there is a condition that the epithelium not only be preserved, but also increase with the growth of its floor. For, should the epithelium disappear, then by the growth of the tissue the gland-canals and acini would simply be obliterated. Finally, from the occurrence described, the farther development of which may be seen at b and c (Fig. 21), there is no doubt that the growth proceeds from the layer of hyaline connective substance which immediately surrounds the gland-bulbs (Fig. 3), and that gradually more groups of gland-bulbs are involved in the manner de scribed. A fibromatous or sarcomatous nodule is then developed in the general tissue, in which the lobules are enveloped with the immediately surrounding hyaline layer, and when once formed such nodules grow entirely central in and out of themselves (in the ideas of the older anato mists); so they can only push the lobules to one side and compress them in tote. The above conception is also supported by the tuberous form of these tumors; the grouping in lobes is very clearly stamped on the younger parts of these tumors, as in Fig. 21; later they disappear as the connecting fibrous bundles degenerate into sarcomatous or fibromatous tis sue. Reinhardt (Deutsche Slinik, 150, p. 121), Meckel von Hemsbach and W. Busch (Chirurg. Beobact., Berlin, 1854, p. 86), were certainly the first who clearly recognized all this, and who, though incompletely, stated it. Rokitanksy, though very much attached to his theory of the outgrowth of the connective tissue, by which he not only explained the growth of cancer structure but at the same time also the extensive growths from cyst-walls, still showed that he completely appreciated these growths, as may be seen from the illustrations in the third edition of his pathological anatomy. II. von Meckel saw a carcinoma of the breast in which he was able to cut from the nipple a dilated excretory duct and so free the growth (Fig. 22). As concerns the tissue itself from which this sarcoma arises, it is partly oedematous, fasciculated connective tissue, rich in cells, and partly myxomatous, lymphoid, but seldom spindle-celled tissue. The previously described preponderating medullary-appearing form of the sar comatous tissue I have not found in these tumors so far, or at least only strewn around in a few places. It may happen, however, that these softer forms of sarcomatous tissue may lead to the formation of prolif erating cysto-sarcoma.