The "Dispersible" Tumors of the Female Breast; With Cases. BY HERBERT SNOW, M.D., SURGEON TO THE CANCER HOSPITAL, LONDON, ETC. FRPM THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, March, 1895. Reprinted from The American Journal of the Medical Sciences, March, 1895. THE "DISPERSIBLE" TUMORS OF THE FEMALE BREAST; WITH CASES.1 By Herbert Snow, M.D., SURGEON TO THE CANCER HOSPITAL, LONDON, ETC. A very common question by hospital patients who apply with a " lump in the breast " is : " Whether this cannot be dispersed ? " While it is needless to remark that such an aim is utterly impossible in the case of a cancerous growth, or that should we vainly essay for the latter merely tentative treatment, we shall only succeed in frittering away what may yet remain of the six or eight weeks period, within which alone modern surgery can reasonably guarantee a radical cure, yet I should like now to point out that a margin of instances numerically considerable yet exists, wherein recourse to the operator's knife is hardly ever necessary, and in which "dispersal " can be effected with no great difficulty. Foremost of the latter is the tumor described in my works, by way of distinguishing it from the connective-tissue mammary growths of later life, as the " fibroma of adolescence." This is found only in the evolu- tionary period of the mamma, i. e., from fourteen to twenty-five years of age. A young girl who wears a tight corset appears with the " lump " aforesaid, varying in degree from a scarcely perceptible thickening of the breast-tissue to a distinct, rounded, rather nodular tumor as large as a walnut. Often several of those are present, and both breasts are affected. The pain complained of varies greatly with the emotional tendencies of the girl; and also (in no small degree) with her frequent resort to tea-drinking. Commonly it exhibits an inverse ratio to the palpable magnitude of the tumor; it is always worst at the menstrual periods. Such growths are the necessary result of obstructed mammary development in early youth, and, so far as I am aware, occur only in a state of civilization. From the huge connective-tissue growths which appear during the decline and devolution of the mammary gland, i. e., after the age of thirty-four, the " fibroma of adolescence " differs in not becoming associated with cyst-formation, an invariable sequel to the adeno-fibroma or cystic fibroma of middle age. The former generally 1 A paper read in the Section of Surgery at the Bristol meeting of the British Medical Association, 1894. 2 snow: dispersible tumors of female breast. yields to suitable management of hygienic and medicinal character; the latter is never cured, or even arrested, without a surgical operation. The old rule sublata causa, tollitur effectus, while not absolute, yet has considerable significance in the case of an organ which, like the youthful mamma, has not yet completed its growth. The aberration of nutrition which produces these small fibrous hypertrophies of the breast-stroma appears largely due to direct pressure, but something must also be ascribed to indirect pressure-effects and to sympathy with the uterus, also struggling for unimpeded development. Moderate the injunctions of fashion in the matter of stays, tranquillize the nervous system, abolish tea, order some absorbent ointment, with frequent local friction, and the "lump" will vanish within a few weeks, seldom more than six. The application I generally prescribe is as follows: Pulv. plumbi iodidi, sj; lanoline, 3vj; adipis ad, ^j. This to be well rubbed in four times daily. Occasionally I have varied this with an ointment of green mercuric iodide, twenty grains to the ounce, employed night and morning; or have substituted two drachms of the (British Pharmacopoeia) red iodide ointment for the same quantity of unguent, plumbi iodidi. With this, fifteen grains of bromide of potassium are taken internally at bedtime, to subdue the always present neurosis. Proceeding on this method, I have not found it necessary to subject any such case to operation since 1889 (i. e., the patient being a young girl) ; and then surgical measures were resorted to only in consequence of the individual's impatience. To sear the mamma with multiple scars is a practice meriting emphatic condemnation, and even such an operation as Thomas's, designed to pre- clude subsequent marking, is hardly ever necessary. The following are cases in point, samples of many similar : Ca.se I.-Ada N., aged twenty-four years, single, seen July 17,1893. At the upper part of the left breast an induration of the parenchyma forming a flattened nodular tumor one inch in diameter. After a single week's employment of the unguent, plumbi iodidi, with lanoline, there was only a slight trace of the " lump." Case II.-Patty D., aged twenty-three years, single, seen January 15, 1894. To outer side of left nipple, flattened and indurated breast- tissue, constituting a "lump" one-half inch in diameter, one year's duration; conspicuously tight stays. On the 22d nothing abnormal could be felt. Case III.-Annie E., aged twenty years, single, domestic servant. Mamma large; ill-defined hypertrophic induration of outer half of left breast, of four years' duration. Treatment from October 28, 1889, till November 25th, then no tumor and nothing abnormal could be found. Case IV.-Louisa Emily M., aged twenty-three years, single, shop- woman ; out-patient April 28, 1890. At lower border of left breast a tumor the size of a hazelnut; noticed three years. Attendance till August 11th ; then " perfectly cured." Has since married and borne two children; writes (December, 1893) to say she has had no further trouble. snow: dispersible tumors of female breast. 3 Case V.-Annie J., aged thirty-seven years, single; out-patient June 11, 1888. At the upper part of the left breast was a tumor of at least several years' duration, equal in size to a large walnut. Operation had been recommended by a cancer specialist. Under inunction by the lead iodide ointment thrice daily entire disappearance of the "lump" in seven weeks. Seen two years afterward; no further breast trouble. Case VI.-Ellen O'K., aged thirty years, married, no children; out- patient January 19, 1891. Hard nodule the size of a pea to outer side of each breast; left largest. Intermittent attendance (from Colchester) for several weeks. On June 1st no trace of either perceptible. Case VII.-Amelia B., aged twenty-four years, single. Nodule the size of a large pea deep in gland-tissue of left breast. Attendance from April 4 to May 21,1887. Use of the iodide ointment thrice daily, with entire resolution. Case VIII.-Rose N., aged eighteen years, single. A tumor as large as a walnut, lobulated, at pectoral margin of left mamma, noticed eight months. Out-patient May 2, 1887; treatment until July 11th, then lost sight of. In December, 1893, states in reply to inquiry, that some enlargement persists, but that all inconvenience has ceased, and that she has never required any further treatment. Case IX.-Emma H., aged nineteen years, single. At the age ot fourteen a tumor as large as an egg stated to have been removed from left breast; now scar three inches long at lower border. External to this, movable tumor size of hazelnut. Attendance from October 3 to November 14, 1889. Seen on January 8, 1894, when no trace was to be felt. Case X.-Fanny S., aged twenty-four years, single. Induration of parenchyma at outer part of left breast, noticed eighteen months. Treated from November 8, 1886, to February 14, 1887, with complete resolution. Case XI.-Marie W., aged twenty-eight years. At upper and outer part of left breast the tissue was hard and nodular, forming a flattened tumor one inch in diameter; noticed two months. A neurotic girl with the usual tight stays. Treated from January 2 till March 19, 1894, when only a faint trace of the induration remained. At first the lead iodide with two drachms of red mercuric oxide ointment; subsequently the former with fifteen grains of alcoholic extract of belladonna to the ounce. The preceding would appear to have been examples of the true " fibroma of adolescence " occurring in young girls, with no obvious cause other than tight stays and a neurotic habit. At a later period small indurated tumors, which cannot be regarded as due to arrested or perverted development and which commonly own an inflammatory origin, are met with. These similarly yield to local treatment. Case XII.-Jane H., aged forty-four years, married, no children. Out-patient August 26,1876. In the left breast an irregularly nodulated, moderately hard induration of the parenchyma, noticed six years. Lan- cinating pain was described, but was referred also to the opposite breast, in which was another "lump" rather smaller. Although the age was so suspicious, a diagnosis of non-malignancy was founded on the dura- tion of the case and the simultaneous affection of both mamms. Under 4 SNOW: DISPERSIBLE TUMORS OF FEMALE BREAST. the inunction four times daily of ung. plumbi iodidi, the condition wholly vanished in about eight weeks. On November 8,1887, the date of the last recorded attendance, no trace of tumor was perceptible. Case XIII.-Louisa P., aged thirty-four years, married, three children. Ill-defined indurated " lump " in left breast following blow three months previously. Inunction four times daily of ung. plumbi iodidi. Attendance from September 12 till December 19,1879. Gradual resolution ; on latter date nothing abnormal to be felt. Case XIV.-Emma H., aged thirty-six years, married, four children Softish movable "lump" at upper part of left breast, noticed three months; in right breast another smaller. A history of cancer in the family. By October 17th both tumors had all but entirely disappeared. Case XV.-Eliza R., aged thirty-eight years, widow. A hard ill- defined tumor at upper part of right breast noticed two years. Treat- ment as usual from September 24, 1880, until January 7, 1881; then complete resolution, leaving no trace of abnormality. Case XVI.-Fanny S., married, one child two years of age. Blow from child seven months previously. Deep in left breast a tumor the size of a walnut, freely movable. Treatment from December 1, 1882, until March 2. 1883, then no trace perceptible. Case XVII.-Elizabeth B., aged thirty-seven years, married, no children. In left breast hard nodule, size of large pea, noticed two years. Treated with unguent, hydrarg. iodidi viridis, night and morning, from January 25 till February 15, 1884, with perfect resolution. Case XVIII.-Emily AV., aged thirty-seveti years, married, one child one year of age, not nursed. Tumor, size of walnut, noticed six months, movable, at upper part of left breast. Treatment as usual till February 23d, then nothing abnormal. Case XIX.-Mary D., aged twenty seven years, single. Out-patient November 19, 1888. Blow two months. Marked induration at outer part of left breast; great pain. On November 26th nothing to be felt. Case XX.-Emma B., aged thirty-four years, single. Seen June 17, 1889. In left breast a nodule size of hazelnut, flattened, not hard, movable, noticed four days. On June 24th no tumor discernible. Case XXI -Martha P., aged forty-six years, married, no children. On July 6, 1885, a tumor the size of a small orange, movable, elastic, at upper part of left breast. Duration one year. Attendance till July 20th, then tumor much smaller. Not seen again, but writes (December, 1893) to say she has had no more trouble. Case XXII.-Eliza B., aged thirty-seven years, married, two chil- dren, youngest eight years of age. Small lobulated tumor at lower edge of left breast, noticed six weeks. Occasional lancinating pain for several years. Treated from September 12 till October 17, 1892. Complete disappearance of " lump." Case XXIII.-Mary L. P., aged thirty years, single. Blow eighteen months ; pricking pain a fortnight. Tumor the size of large bean at upper part of right breast. Treated from November 6,1893, till Decem- ber 4th, then only a trace remained. The following is a somewhat analogous instance of irritative hyper- plasia in the youthful male breast. Case XXIV.-Mr. H., aged twenty-two years, sent for consultation in May, 1891, by Dr. McElfatrick, of Mere. Irregularly lobulated SNOW: DISPERSIBLE TUMORS OF FEMALE BREAST. 5 induration of left breast, forming a flattened tumor one inch in diameter, noticed two to three months, and apparently caused by slight blows when jumping up to a clerk's high desk. Treated for three weeks with the lead iodide ointment, then for five days with lin. belladonna; complete resolution. A third class of " dispersible " tumors is afforded by inflammatory conditions in, or cystic dilatation of, lactiferous ducts. And in this may be included small sebaceous cysts of the areola. Case XXV.-Mrs. F., aged forty-eight years, no children; subject to eczema of the areola. Just below right nipple prominent, very hard red swelling, size of hazelnut, noticed nine days only; no fluctuation. In great consternation, as an operation had just been advised by distin- guished gynecologist. Treatment from November 14, 1893, till Decem- ber 2d. Liniment of iodine locally for a week, then the lead iodide ointment; complete resolution. Case XXVI.-Frances P., aged thirty-seven years, single. Out- patient December 15, 1882. Small soft tumor, size of large pea, one inch from left nipple. After a single week's treatment only faint trace discoverable; no further attendance. Case XXVII.-Jane P., aged twenty-seven years, married, no chil- dren. Above right nipple a pea-like nodule, evidently a dilated duct, of fifteen months' duration. Treatment from April 6, 1891, till April 20th, then nothing abnormal found. Case XXVIII.-Emma W., aged sixty-three years. Sebaceous cyst of areola, blackish in color, size of pea, of two and a half years' duration. Seen October 28, 1889. By November 11th entire resolution. As already hinted, treatment such as that indicated, if adopted for a malignant tumor, will only waste the precious time available for cura- tive eradication before secondary infection has ensued; and it is of no avail for the cystic benign growths which appear during the devolution of the female breast. A prompt and at the same time careful diagnosis is therefore essential. After the adolescent period (25 years) even simple fibromata yield far less readily than before development is com- plete ; and the earlier after their appearance these are dealt with, the better. Africa1! Jodrijal of the MEDICAL SCIENCES. MONTHLY, $4.00 PER ANNUM. WITH 1895 The American Journal of the Medical Sciences enters upon its seventy- sixth year, still the leader of American medical magazines. In its long career it has developed to perfection the features of usefulness in its department of literature, and presents them in unrivalled attractiveness. 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