Symptoms. As a rule, the patient accidentally discovers, while washing or dressing herself, a hard nodule in the breast. Tumors of this kind not larger than a bean are usually painless; they are most common between the sixteenth and twenty-fifth years. Although found on either side, they rarely occur on both

sides at the same time, and are of slow growth; the small cystic spaces found in them are never distended with fluid, and are of minor importance. It is quite possible that they may degenerate into sarcoma, as shown by Lerat's case; but the development of carcinoma is more probable, and Billroth believes that he saw an instance of this kind. I have seen many mammary fibromats both in young girls and in married women. One patient under my observation for eight years, had a uterine myoma, and also a fibroma as large as a hen's egg in the left breast; during this time the tumor showed no change in size, consistence or sensitiveness. Nineteen of the patients above mentioned suffered from such fibromata. I am enabled to confirm Billroth's statement that several tumors are occasionally found in one or both breasts.

2. Lipoma, Fatty Tumor.

Lipoma of the breast is of rare occurrence, although the glandular tissues atrophy after the menopause, and the whole struc

ture of the mammæ is transformed into fatty tissue. The cases hitherto described as lipoma of the breast (Billroth,* Velpeau, Portalupi and Lebert) are not really of this character, the tumor not being a portion of the gland but of the adipose tissue near it. These tumors vary in size, push the gland in front or to one side of them, grow more rapidly than fibromata, are lobulated and elastic. They cause a burning pain, or distress the patient by their size and weight. Since the publication of Billroth's work. the literature of mammary affections contains no case of lipoma of the breast. I have never met with one.

3. The Formation of Cartilage and Bone.

According to Billroth, the only undoubted case of partially ossified chondroma is that described by Astley Cooper. The patient was thirty-two years of age, and had the tumor for fourteen years. It was very painful, and after extirpation had the appearance of cartilage which was in part ossified. Virchow cites cases from Nélaton, Cruveilhier, Warren and E. Wagner in which some cartilage was probably mixed with the other tissues of the tumor. Billroth once found a number of small hard nodules of "true bone" which had developed from the connective tissue. The case described by Velpeau is said by Billroth to have really been calcification in the walls of old cysts, or calcified epithelium, or sand-like bodies in small cysts. Recent literature shows, however, that cartilaginous and osseous tissue is more common in tumors of the breast than has hitherto appeared; the cases reported by Bryk, Pied, Lange and Hacker can hardly be doubted. This subject will again be referred to in connection with sarcoma.

Bryk's patient was sixty-two years of age, childless, and had her attention first called to the tumor eleven months before by the severe pain; it was then as large as a pea. It had grown to the size of a goose egg, was hard, nodulated and painful, and, on section, showed general calcification of the interglandular connective tissue, with destruction and atrophy of the glandular structure.

Hacker (Billroth's assistant) carefully examined a mixed tumor of this kind containing bone and cartilage. It was developed from a cystic ade

*Loc. cit., pp. 45-46.

noma of the gland, which had afterward undergone carcinomatous degeneration. Under the continued irritation, the peri-acinous connective tissue had developed a hyaline myxo-fibroma, and also numerous osseous and cartilaginous bodies.

4. Hypertrophy of the Breasts, Adenoma, and Cysto-adenoma of the Mamma.

Enlargement of the epithelial, connective tissue and vascular elements forming the mammary gland may be general or partial; the former is a rare affection.

General hypertrophy usually occurs at the beginning of menstruation or soon afterwards, cases having been reported by Babington, Benoit-Monteils, Dorsten, Fingerhut, Glück, Grähs, Guston, Hey, Marjolin and Osiander. Occasionally, it appears a few years later, Dahl's case being in a virgin twenty-five years of age. The breast grows rapidly during the first pregnancy (Jördens, Lotzbeck, Skuchersky), and remains stationary after reaching a certain size, in Benoit's case being 105 centimeters (42 inches) in circumference and 10 kilos (25 pounds) in weight. Even in this condition the breasts are rarely equal in size, in my case the left being the larger. The growth seldom begins after the first confinement, as in Cerrutti's case. The skin shows no striæ, but often appears thickened or oedematous; the nipple is not prominent but flat or umbilicated, and the subcutaneous veins are often enormously developed. In young unmarried persons there is no secretion from the gland, but it begins in pregnancy and may be normal in character, as in the second case. The menses are variable, often absent or scanty. The weight of the breast prevents the patient from attending to her usual duties, causing her to be poorly nourished. The tumors are not generally very painful. They may exist for a long time, Grähs' case continuing for 18 years.

In the cases hitherto reported death has resulted from other diseases, or from septic fever after an operation (Huston), from erysipelas (Billroth), or from rupture of an ovarian cyst (Grähs). Grähs and Hess have observed the formation of abscesses and fistula. The patient of whom photographs, taken before and after the operation, are here reproduced, first noticed the tumor

some eight months before the appearance of the menses; it grew rapidly, descended almost to the umbilicus, and had a marked influence upon the circulation. We found a systolic and diastolic cardiac murmur, with the pulse 120 and weak. Examination

showed the kidneys to be healthy. That her enfeebled condition was caused by the tumor was proved by its gradual disappearance after the extirpation. There was, therefore, a probable connection between the development of the tumor and the vascular

system, though it could not be demonstrated by microscopical examination.

Fig. 112 represents a section through the upper portion of the mamma, and shows (a) the cuticle, (b) subcutaneous tissue rich in elastic fibres, (c) a layer of non-striated muscular fibres with many dilated vessels, (d and e) mammary tissue with glandular spaces (f). Several of my colleagues who had the kindness to examine the extirpated gland arrived at different conclusions. Prof. Weigert called it a mammary fibroma. The gland tissue was comparatively scanty, the cells of the alveoli small, their lumen correspondingly dilated. The structure between the latter was much increased, and consisted of an ordinary connective tissue with few cells and little fatty formation. These tumors accordingly are examples of elephantiasis, except that the corium is not involved. Prof. Leopold found that the tissue was chiefly fibromatous, and in some places similar to fibro myoma. He found the blood vessels numerous and having thick walls, but did not consider this