A treatise on the diseases of the breast and mammary region

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Author's Preface

A treatise on the diseases of the mamma is yet wanting in French practice ; for the articles by Boyer, by Astley Cooper, and by writers on the subject in our dictionaries, can no longer hold their ground. The work which I now place before the public is intended in part to supply this deficiency. It was commenced more than thirty years ago. Some of the cases upon which it is based were collected in the Hospital of Tours, at the commencement of my medical studies, under the guidance of those distinguished men MM. V. O. Gouraud and Bretonneau. The experience of large hospitals, consultations grown to be numerous, and a practice of considerable extent, have enabled me to accumulate the particulars of more than two thousand original cases bearing on the whole subject. The result of these investigations, both anatomical and clinical, and the doctrines deduced from them have, however, been partially made known in different publications since the year 1822.1

The duties of the professorship intrusted to me at the Faculté de Médecine have daily compelled me to the reconsideration of these matters, as a number of theses and articles in the journals testify.2 My earliest communications, indeed, excited some attention, both in the press and in the Academy, during

3 See, amongst others, Berigny, 'Gazette des Hôpitaux,' 1835, No. 165, &c. ; Duchesne, 'Thèse de Paris,' 1839, No. 283 ; Colomb, ibid., 1841, No. 14; Traichet, ibid., 1843; Pareja, ibid., 1814, No. 207 ; Gaffarot, ibid., 1846, No. 71; Tizon, ibid., 1847, No. 42 , Moisin, ibid., 1851, No. 230; Doré, ibid., 1851, No. 218 ; Robelin, ibid . 1852, No. 32, &c.

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the years 1824 and 1825,1 and my article on the breast in the f Répertoire des Sciences Médicales/ which seems to have served as the starting points for the important memoirs of M. Nekton on inflammation, and of M. A. Bérard on tumours of the mamma, shows what views I entertained on the subject in the year 1839; and thus it happens that numerous fragments of the present work have long been before the public.

The examination, the study, and the discussion of facts which continually present themselves at the bedside of the sick, have perpetually interfered to delay its completion; still, when once the impulse had been given, it was impossible not to persevere. Daily compelled to submit my opinions to the test of practice, I have had to modify and by degrees to correct them by the light which continually flashes from experience and reflection. My present work has thus been remodelled several times.

Its completion, however, has never been interfered with by deficiency of material, for no other observer has, I believe, had a similar mass to work upon. The consequence has been that without absolutely neglecting what has been accumulated by my predecessors, T have nevertheless been able, almost throughout, to content myself with my own observations. Even with this restriction my embarrassment has been great. As the cases alone in my possession would have filled more than a volume, I have limited myself to narrating only a few of them, and have simply tabulated the rest. To their illustration numerous drawings would also have been necessary, but this the price of the work would not permit, for it has been my object to place it within the reach of every one.

Of the three principal parts which compose it, the first, that which treats of inflammation, does not appear to require any preliminary apology. The classification that I have adopted, founded as it is upon surgical anatomy, and moreover susceptible of association with any other, may be improved or modified ; but can scarcely be altogether rejected.

The other two sections, which relate to innocent and to malignant tumours, do not stand in the same position. The discussions on the subject which I entered into in various publications, and at the meetings of different scientific societies, during the years 1825 and 1844, show that my endeavours have always been

1 Mémoire on a remarkable case of cancerous disease, 1825.

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directed to the removal from the category of cancers of such tumours as, from their nature, might or ought to be kept distinct. So much confusion prevailed on the subject, and the difficulties were so great, that thirty years of assiduous labour have been insufficient to dissipate entirely the doubts and uncertainty that envelope it.

Meanwhile, one important result has been obtained ; for henceforth we may admit as demonstrated that, out of 400 cases of tumours, confounded together under the common name of cancer, there were nearly a hundred which were not cancerous, and which we can now distinguish at the bedside of the patient. Further study, and the natural progress of science, will, I am persuaded, still more augment this proportion ; but if the further I advance the larger becomes the number of innocent tumours in my tables, we are not therefore to conclude that they are more common now than formerly ; no, it is solely that as our powers of diagnosis improve this number naturally enough increases year by year. There is, therefore, reason to hope that, starting from this point, surgeons will one day or other be enabled to contract the circle of genuine cancer to a still greater degree.

Innocent tumours are not all of the same species ; and as in former times I often confounded them together, I formerly gave descriptions which, though applicable to some, cannot be applied to others. Hence it is that I have by turns made use of different names to distinguish them. In the first place it is essential to make at least two groups : one of tumours which are really hypertrophies, the other of tumours of new formation. The young Parisian School, resting upon data derived from the microscope, makes no distinction between these groups, but includes them all under the common title of partial hypertrophy of the breast. According to the microscopists, in fact, non-cancerous tumours are due to the accumulation of epithelium in the radicles of the milk-tubes and to the hypertrophy of a certain number of the mammary acini. This doctrine is satisfactory as regards the first group, but does not appear to me by any means so as regards the second.

Genuine hypertrophic tumours differ in so many characters from adenoid growths that it is difficult not to keep them separate. Even in the month of May of this very year, and again in November, two new examples of the most conclusive kind were brought under my notice. In both patients — the one a healthy young xii AUTHOR'S PREFACE.

woman, regular, the mother of two children ; in the second an unmarried person, forty-four years old, hump-backed, and of broken constitution and health — the tumours, which were of the size of an egg, and softened towards the centre, were undistinguishablc from the mammary tissue, with which, indeed, they were found to be everywhere continuous without appreciable line of demarcation. Placed side by side with adenoid tumours removed at the same period from other women, these growths were as different in their appearance as, for instance, is a fatty tumour from an hypertrophy of the tongue. The microscopical structure was, it is true, the same in both cases ; but I have stated in the body of this work what amount of confidence should be accorded to this evidence.

I may here narrate a case of some importance. In a woman who was operated on for an enormous adenoid tumour, which was ten pounds in weight, eighteen months afterwards there arose at the border of the pectoralis major, a secondary globular and moveable growth, which I was able to remove by simple enucleation, and which, in other respects, both before and after the operation, presented all the appearances of other adenoid tumours. However, M. Follin, who made a very careful microscopical examination of it, sent me the following note :

" The tumour was composed of two different portions. The one, the cortical portion, dense, fibrous, and of a gray-white colour, slightly opaline, creaked under the knife, and on pressure gave exit to nothing but a serous transparent fluid, altogether distinct from the milky juice of cancerous tumours. The other, the central portion of the mass was throughout made up of yellowish deposits, grumous, and mixed in some parts with blood which had not lost its colour. Under the microscope the cortical portion was composed of the following elements : 1st, of a large number of elongated and elipsoid bodies, provided with a central nucleus, and terminating in rounded or thread-like ends ; 2d, of fusiform bodies much elongated, slightly raised in the centre, and furnished with tails sometimes of great length. These fusiform bodies heaped together so as to form a somewhat dense mass constituted the fundamental part of the tissur.

"As for the central portion, it did not exhibit to me any definite structure. I observed in it nothing but an assemblage of fibres, and a few blood-globules, which were deposits of blood in process of decolor ization."

AUTHOR'S PREFACE. xiii

Thus there were in this tumour neither epithelial cells, nor closed tubes, nor the elements of breast tissue, and yet how can we deny that it was of the same species as the one originally removed from the mamma ? And, moreover, what was this tumour, which was as large as the two fists, and bore no resemblance whatever to the lymphatic glands, if it was not a tumour by deposition or by new formation?

The patient here referred to had scarcely recovered, when there came into the ward another female with an adenoid tumour of about forty pounds in weight, the like of which I have never seen. I maintained the innocent nature of this growth, notwithstanding, according to popular belief, it bore every resemblance to encephaloid ; and although, according to the microscope, it was of hypertrophic composition, yet it was foreign to the proper mammary tissue.

Science and practice may therefore unite in inquiring whether, at all events, in the present state of our knowledge, adenoid tumours are not confounded with simple partial hypertrophies of the mamma, just as much as are fibrous tumours with hypertrophy of the uterus.

As for genuine cancers, I have found it very difficult to classify them. Microscopical researches, the assistance of which I sought so far back as the year 1830, and which I have promoted on all occasions, have not, in my opinion, as yet supplied us with data sufficiently definite to serve as the foundation of a good classification of tumours. I think I have, contrary to the assertions of the ultra-microscopists, incontestably shown — 1st, that that cell, which is called the cancer-cell, is not the specific element of cancer ; 2d, that well-marked cancers may not contain this cell at all ; 3d, that it has been found in non-cancerous tumours.

In order to remove every pretext for doubt upon the subject, I have only made use of facts furnished by the microscopists themselves, and especially by M. Lebert. The ' Physiologie Pathologique ' and the ' Traité du Cancer ' of this author, works as conscientious as they are laborious, show that a multitude of tumours furnished by my practice have been examined and analysed by him. Consequently we have both witnessed the same facts. If, then, M. Lebert had limited himself to affirming the existence of certain forms of cells in the tumours of which he speaks ; if, in one word, he had confined himself within the bounds of pathological anatomy, I should have no objection to xiv AUTHOR'S PKEFACE.

urge, and should not, to my deep regret, have found myself under the necessity of rejecting his interpretations, both theoretical and practical, on the subject of the cancer-cell.

"Without speaking of M. Millier, and of some other eminent German anatomists, who deny the specific nature of the nucleated cell, I may observe that M. Alquié, of Montpelier ; M. Michel, of Strasbourg; MM. Marjolin, Robert, Forget, and others, in Paris, have, on their side, arrived at conclusions similar to my own.1

Mons. Lebert, and, following him, M. Robin, are, it seems to me, mistaken in assuming as settled that which is still a matter of doubt, viz., what species of definite cell forms the fundamental element of each kind of tumour. In making the assertion, that each tumour made up of homologous cells ought to be classified amongst innocent growths, and that every tumour in which there exist heterologous cells, must necessarily be a cancer, they have drawn their conclusions too rapidly. To say that cancers of the lips, face, arms, uterus, or penis, and cancers of the integuments in general, are only hypertrophied follicles, or masses of epithelium ; and that verrucse, corns, warts, horny growths, steatomatous tumours, and the above-named cancers, are identical in kind,2 must even, à priori, appear exceedingly strange to all experienced surgeons. Before the time of Sertuerner, analytical chemistry found in opium nothing but the elements of gum ; but should we therefore have been justified in concluding that gum and opium are identical ?

Consistently with his doctrine, M. Lebert has not hesitated to maintain that those ulcers, prominent eruptions, tumours and vegetations of the lips or face, &c, which are known to surgeons under the name of noli me tangere, herpes exedens, and cutaneous cancers, are not geuuine cancers, but only pseudo-cancers, cancroid productions ; and further, that when completely removed by operation, they are not liable to reproduction. In this way, too, he endeavours to explain the circumstance that cancers of the lips, for example, only reappear in their original situation, and are not usually followed by secondary formations.

Two mistakes attach to these propositions. In the first place, it is not true that cancers of the lips are not liable to return ; perhaps they grow again with even as much obstinacy as cancers

2 See Mayor. 'Thesis,' 1846, No. 8.

AUTHOlt'S PKEFACE. xv

of the breast ; and, in the second place, it is certain that when once operated upon, they re-appear as readily at a distance as in their original seat, and it is also certain that they may become generalized. 1 Avas as well aware of this ten years ago as I am now; but then the microscopists object, that up to that period we confounded, in practice, epithelial tumours with true cancers, and that, therefore, observations, instituted anterior to modern researches, should not be brought into the question. Such a reason for not taking them into the account can have no weight with me; for it is evident enough to me that cancroid is precisely the disease for which surgeons have always operated under the name of cancer.

Nevertheless, the question raised by such a man as M. Lebert deserves examination. I therefore once more apply myself to it. All the cases of cancroid that I have met with have been submitted to microscopical examination, and I do not hesitate to assert, that in no instance have the microscopists seen me mistake a tumour of this kind for any other at the bedside of the patients. Now the result of my modern practice shows that the pseudo-cancers, like the real cancers, return with a deplorable tenacity.

Daring no longer to deny the fact, M. Lebert at first answered that this return may be due to a portion of the disease having escaped the knife. A new error ; cancroid tumours do not re-appear exclusively in the neighbourhood of the primary tubercle; they show themselves under the jaw, under the ear, and in the lymphatic glands of the neck, as well as along the borders of the cicatrix. Driven back upon this point, the advocates of the Cell doctrine entrench themselves in another proposition as little stable as the preceding. If, say they, cancroid disease occasionally does recur at some distance from its primary seat, it is, at any rate, only in the lymphatic structures of the part, and never in the viscera ; if, in short, the disease does become multiplied, it is in the same way as scrofulous tumours or tubercles, but not like genuine cancers. A worthless plea, which close observation overturns in the same fashion. I have seen cancroid disease of the lips re-appear, without the slightest continuity, in the substance of the bones, in the body and ramus of the jaw, sometimes of the corresponding, sometimes of the opposite side, and occasionally, when the disease has commenced in the inferior half of the face, even in the upper jaw ; and I have also seen it reproduced in the liver xvi AUTHOR'S PREFACE.

and elsewhere. I have witnessed more than this. In the case of a man, in whose labial cancer, removed two years before, there were only epithelial elements, the secondary disease, which appeared beneath the jaw, and in the region of the parotid, presented a considerable number of cancer-cells. In a patient of M. Maisonneuve, the tumour in one half of the jaw was filled with this cell; but the reproduction occurring in the other half of the bone, which was removed at the expiration of a few months, there were discovered nothing but fibro-plastic structures. The examination in both these cases was instituted by the ablest microscopists.

Thus, let us not. deceive ourselves ; cancroid disease is cancer. It eats away ; it disorganizes the neighbouring parts one after another; it spreads by continuity aud by dissemination; in the neighbourhood and at a distance, either by means of the lymphatic system, or in some other way, just like cancer; it never undergoes spontaneous cure, and always ends by occasioning death; it is influenced by no treatment that we know of, either local or general, and its destruction by cutting instruments or caustics is almost as often followed by reproduction as cancer properly so called.

Supposing, even, that it be reproduced only in the course of the lymphatics of the part, from the moment that we admit its fatality, what advantage can there be in making out that it is not a cancer ? To say that death ensues from disorganization of the affected parts, and not by general infection, will, I should think, prove but a sorry consolation to the patient, seeing that, in the one case as in the other, he is fated to die of the disease.

The fibro-plastic cell stands in the same position as the epithelial. It has never seemed to me possible that a structure which forms the basis of the natural fibrous tissues of inflammatory induration, of indurated chancres, of hypertrophied glands, of fibrous tumours of the uterus, of conjunctival vegetations,' and so on, can form the specific element of malignant tumours. The microscopists themselves, astonished that it should be so, have endeavoured to transfer all fibro-plastic growths into the category of innocent tumours, although many of them have hitherto been classed with cancers, amongst which, unfortunately, they must still remain.

Napiform and cartilaginous, as well as fibro-plastic tumours, do not reappear exclusively in their original scat, or because a part nf the disease has been left behind at the operation. Hut like

AUTHOR'S PREFACE. xvii

cancroid, and cancerous growths, they ' are regenerated in all parts, in consequence of their inherent nature. After amputation of the leg, foot, or hand, I have seen them reproduced in the substance of the thigh or arm. When they return, it is rare for the reproduction to take place in the lymphatic glands; neither, however, is the reproduction due to continuity of tissue.

Amongst the cases of the generalisation of these tumours that have occurred in my practice, there are three which seem to me to settle the question.

Simeon Delaporte,1 an adult, thirty-two years of age, was operated on three times, for a cartilaginous tumour of the thigh. The disease returned again, and the limb was amputated. Some months afterwards, the patient died, and at the post-mortem examination, a number of fibro-plastic tumours were found in both lungs, the exact nature of which was determined microscopically by MM. Verneuil and Follin, who sent me the following note, confirmatory of the observations of M. Giraudet. " The right pleura was thickened over a surface of several fingers' breadth, and in both lungs were found a large number of tubercles of variable size, composed of tissue analogous to that which existed in the stump.

" Careful microscopical examination detected nothing in these morbid products, but the usual elements of fibro-plastic tissue ; in the pleura, the fusiform bodies were well developed, and in the medullary tissue of the femur some perfectly distinct fibro-plastic globules were recognised."

A stout young woman, of excellent constitution came into the hospital for a napiform tumour of the upper part of the left arm. This tumour, which rapidly attained the size of the body of an adult person, underwent softening, and caused the death of the patient at the end of a few months. At the post-mortem examination, the lungs were found stuffed with tumours of the same kind. The third case was that of a sarcocele in a young person ; and after castration new tumours became developed in the abdomen.

Before the patient's death, the microscopists, relying on the existence of fibro-plastic fusiform bodies, and on the absence of the cancer-cell, maintained, in opposition to my opinion, that in these three instances the tumours were homologous, and conse-

1 See Giraudet, ' Thèse,' No. 184, Paris, 1852.

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quently innocent ; and in the dead body, also, they ascertained the fibro-plastic nature of the internal tumours. The case of sarcocele occurred in the year 1847, and on that occasion, M. Lebert sent me three full notes, the first relating to the tumour of the scrotum, the second to the tumour in the abdomen during life, and the third to the results of the post-mortem examination, all of which show how, even then, their author struggled against a truth from which he can no longer escape.

1st Note. — At the time of the operation. — "A young man, eighteen years of age, under the care of M. Velpeau, had a fibrous tumour of the testicle, which being supposed to be cancerous, although it hardly presented the characters of that disease, necessitated castration.

" From no part of it could pressure extract any fluid resembling cancer-juice; and on forcibly scraping it with the scalpel, nothing else was obtained but a transparent matter like synovia.

" On examining the tissue of this tumour under the microscope, it was easy to convince myself that it was nothing but an ordinary fibro-plastic tumour, and that of the best kind. In parts, the fibrous tissue was completely organized, and enclosed in its interstices numerous plastic nuclei."

2d Note. — Before the death of the patient. — " I should be unwilling that you should understand what I said to you this morning respecting the patient with the abdominal tumour, consecutive to the operation for sarcocele, as a retractation of the opinion which I formed of the growth at that period. It was evidently different from ordinary cancerous sarcocele ; it was destitute of cancerous juice and of tubercular-like masses of substance. The microscope nowhere discovered the cancer-cell, but only fibres, narrow, fusiform bodies, and fibro-plastic globules. I maintain, therefore, that the tumour had not the characters of cancer, but those of fibrous, fibro-plastic, fibrocolloid growths, &c. In spite of this, however, the examination of the present condition of the patient leads me to believe that he labours under cancerous cachexia, and that he has tumours of a malignant kind in his abdomen, although it is not impossible that these may be non-cancerous tumours, which, by their development, and by the compression they exert upon important organs, give rise to serious constitutional disturbance.

AUTHOR'S PREFACE. xix

" I confess that this coincidence l)ct\vcen a fibro-plastic tumour and cancerous tumours in the abdomen, is exceptional ; but theory must, in all cases, yield to facts and observation, and Ave must always acknowledge what is unusual in a case, even when it does not coincide with the other results of our investigations. However, you who bring so much sagacity to the appreciation of facts, and to clinical research, will understand that we may frankly admit that a case is contrary to the results of previous investigation, without being in the slightest degree shaken, respecting doctrines that have been suggested by hundreds of careful observations.

"I am your debtor for so many marks of good will ; you have afforded me so many opportunities of personally examining the structure of morbid products, that I shall be glad if it be in my power to exhibit to you the results of researches that you have so long favoured, and which will infallibly more and more play a part in the investigation of the intimate nature of disease, purged, however, by time, of errors inherent to new and very difficult research es.5 '

3d Note. — After the death of the patient. — " I was present this morning at the examination of the body of the young man with abdominal tumours, consecutive to the operation for sarcocele. It is certain that the speedy progress of the disease, nine months in all from the commencement ; the rapidity with which the tumours were developed in the abdomen after the operation ; and, finally, the general cachectic condition of the patient, favour the diagnosis that you originally made. Nevertheless, the tumours removed at the autopsy, on microscopical examination, nowhere exhibited the characteristic cancer-cells, but merely those of fibro-plastic tissue, such as existed in the tumour of the testicle which you had previously removed from the same young man. On the one hand, therefore, we have the progress and many of the principal characters of cancer ; and on the other, a marked difference in the elementary structure of the tumour, which was recognised also by M. Corvisart, independently.

" As, on the other hand, fibro-plastic elements are found in tissues evidently non-cancerous — such, for instance, as the little conjunctival vegetations which sometimes arise after the operation for strabismus, or in the lardaceous tissue of joints chemically inflamed, &c. — it seems to me that we should regard this case as xx AUTHOR'S PERFACE.

one of a general diathesis of fibro-plastic tumours, running a course analogous to cancer.

" Thus, however we may explain it, the fact still remains, that the characteristic element of scirrhus and encephaloid was nowhere found, notwithstanding the likeness which the tissue bore to encephaloid, and which the progress of the disease presented to cancer.

" I am, &c,

" H. Lebert."

The point, then, is settled. The microscope discovers only homologous cells in tumours which run their course, and terminate in precisely the same way as cancers.

There remain scirrhus and encephaloid. Can we, at least in the case of these two forms of the disease, acknowledge the results furnished by the microscope ? If its evidence be erroneous as respects cancroid, chondroid, or fibro-plastic tumours, it runs great risk of being untrustworthy throughout on the subject of cancer. Since different varieties of cancer may exist with homologous cells alone, the existence of heterologous cells is necessarily insufficient to characterise cancer : and, as we have seen, I have elsewhere proved that this latter cell may be wanting in genuine cancer, and be found in tumours that are not cancerous at all. Numerous cases, which cannot be questioned, moreover, enable me to affirm that tumours, cancers, endued with the specific cell of the most marked kind, the most complete in character, in short, with the typical cell, when once extirpated, may never return.

The preceding remarks ought not, however, to be considered as classing me amongst those persons who despise the microscope. On the contrary, I accept the facts that the instrument has brought to light, and only contest their application. Amongst other things, I do not deny that a marked and easily recognised distinction exists between what is called the cancer-cell, and the cells of other kinds of tumours. I admit, also, that this sort of cell, that is to say the cancer-cell, is, in truth, absent in the majority of innocent tumours ; and, as clinical experience has, on its side, long ago proved that these tumours differ from cancer, I find that the microscope, in this point of view, merely confirms the results of simple observation.

AUTHOR'S PREFACE. xxi

However, I must add, that when reduced to these terms, the question cannot be unreservedly decided. Tumours in which microscopists have discovered neither cancer-cell nor cancerous nuclei, are not the less genuine cancers to the surgeon. I am persuaded that the cancerous element is specific, and that if it be not discovered in certain tumours of really cancerous nature, that is only because it is not yet sufficiently well known. Perhaps even there may be divers sorts of cancer-cells. After all, the question has been discussed for so short a period — these cells have hitherto been studied by so small a number of competent observers — the whole subject, in short, constitutes so new a world of investigation — that science is still but at its dawn, or starting point, respecting it ; and I entreat the rising generation, whilst, on the one side, it gives credit to what the microscope has conclusively shown, not, on the other, to forget what ages of experience and bedside observation have also shown to be incontestable.

To sum up, what I question is, that up to the present time the so-called cancer-cell has been shown to be the sine qua non, or initial element of cancer; and we may ask, whether the diagnostic value of this cell, which has already been shaken by the labours of Dr. H. Bennett, of M. Virchow, and of M. Courty, will not entirely disappear, if M. Mandl, who has met with cells in the tissue of the healthy lung identical with the cancer-cell, should succeed in proving, by means of a higher magnifying power, the exactitude of his assertions ?