As already remarked, the consistence and increase of the glandular epithelium play a very important part in the formation of these tumors. It is a tolerably regular occurrence for the epithelium in all the gland spaces and in the acini to become many-layered, and to take the character of cylindrical epithelium on the surface. Here and there it takes on active growth so that the spaces are entirely filled with epithelial cells, which• finally roll together into spherical forms. I have seen no case in which this balling together of the epithelial cells lead to the formation of pearls; but V irchow mentions these growths in cysto-sarcomata of the mamma. Most frequently the epithelium is dissolved into homogeneous mucus, which then fills and expands the gland-sarcoma; some exudation may be added from the vessels to thin this mucus.
Symptoms and Course.—These proliferating cysto-sarcomata of the mamma, the progliostic signification of which depends not on the contents and mass of the cysts, but on the histological character of the interstitial tissue, always possess sufficient peculiarities to separate them from fibro sarcomata, soft sarcoma and adenoma, though it must be remembered that these forms of tumors are not to be sharply differentiated anatomically, and there may be many combinations of them.
They originate most frequently in the second or third decennium, more often in the married than in the unmarried, and most frequently in women who have borne children, less frequently in sterile women. Their upper surface is marked by large nodules; their consistence is dif ferent in different places; where the cysts lie near the surface, distinct fluctuation is often obtained, and in other places, the surface is firm or soft. They are always encapsulated and movable in the gland, never adherent to the thorax, even when they grow to giant size. Their growth is very variable; there are cases in which they only attained the size of a hen's egg in two or three years, and others in which, in the same time, they have attained the size of a child's head. The growth is usually pain less; they are not painful to touch or light pressure. In two cases noted by me, there was an appearance as though the cysto-sarcoma arose from fibro-sarcoma, which had remained dormant for many years (in one case 19 years).
Sometimes these tumors grow to enormous size as in the following case from Velpeau: Mrs. A., 54 years old; tumor began 4 years ago; menopause 2 years ago; one year ago the tumor was the size of the fist, but has grown.
rapidly since then. Patient refused operation. The tumor varied in consistency; the base was solid, with large fluctuating spots in other parts. The skin was thinned, and was traversed by large veins; below and ex ternally there was slight ulceration. The greatest vertical measurement
was 14.14 inches, transverse 11.8 inches, and greatest circumference 44.3 inches. The woman was very much emaciated and very weak. Over 3 quarts of fluid, with tumor detritus, were evacuated through two punc tures. Weight of tumor 44 pounds. Unfortunately nothing is said of the axillary glands, or whether metastatic tumors were found in internal organs. Death from marasmus. On account of the number of small cysts, the tumor is sufficiently characterized as cysto-sarcoma, though Velpean calls it adenoid. The cases taken by Beigel from Pemberton and described as encephaloid tumors probably belong in this category. At all events, the cases illustrated by Cooper belong to such giant cysto sarcomata. All these tumors were observed in old married women who had borne several children; the origin generally dated from the beginning of the sixth decennium, and coincided with involution; the growth was very rapid, these enormous tumors being formed in from two to four years, usually without involvement of the lymphatic glands, and without internal metastases. Ulceration has been observed several times, partly through spontaneous rupture of the cysts, partly from incisions into them, and by necrosis of the very thin skin, here and there adherent to the tumor.
Erichsen describes a case in which the sarcomatous masses grew, in a cauliflower-like mass, from the opened cyst. Of the nineteen cases seen by me, fourteen were married and five were unmarried. I can prove that twelve cases remained free from recurrence for from two to ten years after operation. Here was recurrence occurring locally, for, as a rule, only the tumors were removed, not the whole of the mammary gland. I operated on one woman five times in four years; there was quick recurrence. The whole gland has now been removed and there, has been no recurrence f9r three years. In one case metastases occurred in the pleura, ribs and pericardium without infection of the lymphatic glands. In another case there was exquisite left-sided cysto-sarcoma with local recurrence and with out infection of the lymphatics, and somewhat later exquisite right-sided carcinoma with involvement of the axillary glands, and death from inter nal carcinomatous metastases.
In general, it can be truly said that even if cysto-sarcoma of the breast grows to such enormous size, it is still seldom infectious. Unfortunately the anatomical descriptions in the journals are not sufficiently exact to draw any conclusions as to whether the cases with infection of the lym phatic glands and with internal metastases had especial histological pecu liarities by which the prognosis could be determined. Further observa tions are needed in order to make a more extensive study.