Encyclopaedia Britannica, 11th Edition, "Malta" to "Map, Walter" / Volume 17, Slice 5

by Various

Chronic Mastitis is of frequent occurrence in women who are past middle age. The part of the breast involved is enlarged, hard, and more or less tender and painful. It is sometimes impossible clinically to distinguish this disease from cancer. True, the tumour is not so definite or so hard as a cancer, nor is it attached to the skin, nor to the muscles of the chest wall, and if there are any glands secondarily enlarged in the arm-pit they are not so hard as they may be in cancer. But all these are questions of degree. It is, of course, highly inadvisable to leave it to time to clear up the diagnosis, for a chronic mastitis, innocent at first, may eventually become cancerous. If in any case the difficulty of distinguishing a chronic mastitis from a malignant tumour of the breast is insuperable, the safest course is to remove the breast and have it examined by the microscope. The suggestion, sometimes made, as to the preliminary removal of a small piece of the tumour for examination is not to be recommended.

A simple glandular tumour, fibro-adenoma, is apt to be found in the breasts of youngish women, who may possibly give an account of some blow or other injury; there may, however, be no history of injury. The tumour is smooth, rounded or oval, and lies loose in the midst of the breast; as a rule it is not tender. It is not associated with enlarged glands in the arm-pit. The tumour had best be removed, though there is no urgency about the operation, as the growth is absolutely innocent. There is, however, no telling as to what course an innocent tumour of the breast may take as middle age comes on.

Cysts of the Breast.—A galactocele is a tumour due to the locking up of milk in a greatly dilated duct. Other forms of cystic disease may be due to serous or hydatid fluid, or to thin pus, being surrounded by fibrous walls. Such cysts are best treated by free incision, and by passing a gauze dressing into their depths. If the tissue is occupied by many cysts, the whole breast had better be removed.

Cancer of the Breast may be met with in men as well as in women; in men, however, it is very rare. It is commonest in women between the ages of forty and fifty. It is sometimes met with in women of twenty; and the younger the individual the more malignant is the disease. Married life seems to have no effect as regards the incidence of the disease, but it often happens that a breast which gave trouble during the period of suckling becomes later the subject of cancer; in other cases there is a clear history of the attack having followed an injury. It is, thus, as if inflammatory changes in the breast were the direct cause of a later cancerous invasion. Though it is impossible to affirm that heredity has a great influence in the incidence of cancer, it is, nevertheless, remarkable that the members of certain families are unusually prone to the disease.

The chief feature of a cancerous tumour of the breast is its great hardness. The technical name for the growth is scirrhus (Gr. σκίρος, or σκίρρος, any hard coat or covering, stucco), from its stony hardness. The tumour consists of a dense framework of fibrous tissue, with groups of cancer-cells in the spaces. The malignancy of the disease depends upon the cells, not upon the fibrous tissue. In young subjects the cells predominate, but in old ones the contraction of the fibrous tissue throughout the breast compresses and destroys the cells, and this sometimes to such an extent that there is at last nothing left at the site but contracted fibrous tissue, all trace of malignancy having disappeared. This variety of the disease is found in old people, and is called atrophic cancer.

The cells of a cancerous breast are apt to be carried by the lymphatics to the lymphatic glands in the arm-pit, and by the bloodstream to the spinal column and to other parts of the skeleton, and sometimes to the liver, which thus becomes large and hard, or to the other breast.

As the fibrous tissue around the tumour becomes invaded by the new growth it undergoes contraction (much as a string becomes shorter when it is wetted), and as this shortening of the fibrous bands increases the nipple may be retracted, and the breast may be closely bound down to the chest-wall; and, further, the skin overlying the tumour may be drawn in towards the tumour so as to form a conspicuous dimple. Later, the nutrition of this patch of skin may be so interfered with that it mortifies or breaks down, and thus a cancerous ulcer is produced. This ulcer slowly spreads, and its floor is covered with a discharge in which septic micro-organisms undergo cultivation; in this way the ulcer becomes highly offensive. By the use of antiseptic lotions and a frequent change of dressings, however, all unpleasant smell can be checked or prevented. As the ulcer extends it is apt to implicate large blood-vessels, so that serious, and sometimes alarming, haemorrhages take place. And if the breast had previously been in pain, the bleeding is likely to give great relief. But repeated haemorrhages bring on increasing exhaustion, and thus materially hasten the end.

There is at present only one trustworthy treatment for cancer, and that is its free removal by operation. The entire breast and the nipple must be sacrificed. At the present day the operation itself is not a “dreadful” one. To be successful it must be very thorough, and it must be done early. The patient, being under an anaesthetic, feels nothing, and the subsequent dressings of the wound are attended with scarcely any pain. There need be but a couple of days of confinement to bed, and when the wound has soundly healed the patient may be encouraged to use her arm. Should there be recurrence of cancerous nodules in or about the wound, their removal should be promptly and widely effected. The writer has records of one case in which between the first operation and the last report there was a space of over twenty-nine years, and another of fifteen years. Each of these patients had one extensive operation, and four or five smaller operations for dealing with recurrences. Each of them, however, might be considered unlikely subjects for further return.

For a superficial cancer the X-rays may be of service, but many applications of the rays are likely to be needed, and the case may possibly refuse to yield to their influence, and, after loss of valuable time, the disease may have eventually to be removed by the knife. The great advantage which the treatment by the knife offers over every other method is that the growth can be cleanly, efficiently and promptly removed, and, with it, all the affected lymph-spaces, and the lymphatic glands which are secondarily implicated.

As regards the value of radium in the treatment of cancer of the breast, the high expectations which were somewhat widely associated with this newly-found element early in 1909 must be said to have been unjustified by any precise results. Injections of radium salts have been made into the substance of a cancer, and tubes of aluminium containing the salt have been introduced into the growth, but no deep cancer has thereby been cured. Radium has also been exposed again and again on the surface of the affected breast, but similarly with no great result. Unfortunately, whilst one is experimenting in the treatment of an operable cancer, the epithelial cells of the growth may be making their way towards distant parts, where no rays or emanations could possibly reach them. Whatever may be the future of radium as a therapeutic agent in the treatment of cancer of the breast, it is certain that, on the facts as known at the beginning of 1910, the only safe course is to remove the breast by direct operation, together with the associated lymph-spaces and lymphatic glands. And if this is done promptly and thoroughly cancer of the breast will come more and more into the class of curable diseases.