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compare the physical signs of the innocent and malignanttumours in their respective classes (viz., solid, soft, and a

cystic) in order that the difficulty of diagnosis may have for n

him its full significance. tlI think no commentary is required upon the individual a

cases, but one or two points require emphasis. The first, to e

which attention has alreadv been drawn and which is well o

known, is the difficulty of diagnosis between a small hard ttumour and a small tense cyst, especially in a fat breast; v

the second, that a discharge from the nipple, be it clear or t

blood-stained, is no index to innocency or malignancy ; i

thirdly, that in doubtful cases glandular enlargement is no 1:criterion of malignancy, being indeed rather the reverse in c

many cases ; and fourthly, that the physical sign, dimpling of c

skin, is not necessarily a proof of the presence of a growth. 0

I lay stress upon this, as in my belief too much weight is tlaid by certain writers upon this sign as pathognomonic of t

growth, whereas chronic mastitis is responsible for this sign (

in more cases than is believed. The same criticism is r

applicable as regards retraction of the nipple in non- imalignant cases (vide Cases 14, 15, 16).

In conclusion, I quote one more case, not as an exampleof a doubtful tumour, as the diagnosis was unhesitatingly (

made that it was innocent, but to emphasise once again the t

desirability of removing all, tumours of the breast whenever (

possible and having them examined by a skilled pathologist. This case, though not definitely malignant, showed enough fmicroscopical evidence to justify its treatment, although undoubtedly it was clinically innocent. The patient was 20 years of age and unmarried. Right

breast, two months. At the outer periphery of the breast was a minute hard nodule of the size of a pea, freely move- able. No enlarged axillary glands. No mastitis in either tbreast, tTreatment.-Local excision.

Pathological report.-Small tumour of the size of a pea. E

Breast tissue undergoing hyperplastic changes consistent iwith commencing malignancy.

I am indebted to the staff of the Cancer Hospital, z

Brompton, for their kind permission to make use of thesecases, and to Dr. Alexander Paine for the pathological reports. The photograph is of Case 14 (adenoma), and tfor it I am indebted to Dr. T. J. English.

PEAU D’ORANGE IN ACUTE MAMMARYCARCINOMA: ITS CAUSE AND

DIAGNOSTIC VALUE.BY ARCHIBALD LEITCH, M.B. GLASG.,

PATHOLOGIST TO THE CAIRD CANCER RESEARCH LABORATORY, DUNDEE.

THOUGH it is true that no constant relation exists betweenthe microscopic appearances of a mammary carcinoma andits clinical course such as to enable us to say that a par-ticular histological type characterises a slow or rapidevolution, yet in extreme cases there is a not infrequentrelationship between them. Thus the growth to whichclinicians attach the name of scirrhus is generally charac-terised by the preponderance of dense fibrous tissue over theamount of massed epithelial cells, and, on the other hand, thevery rapidly growing carcinoma shows a relatively excessivecellularity. It may, however, happen that a slowly growingcancer is surprisingly cellular and a rapidly growing malignanttumour densely fibrous, and this point seems to be brought outclearly in the case of mouse cancers by Bashford and hiscolleagues. The histological appearance of a cancer,

though sometimes suggestive of, is no gauge to, its degree ofmalignancy; and, practically, when we speak of degrees ofmalignancy in tumours we have to depend on the clinicalevolution of the case. I do not know any criteria thatwill enable the pathologist to predict a slow or a rapidcourse in the disease. Starting from the atrophic scirrhuscarcinoma lasting for years and regarded by some, to mymind erroneously, as a malignant tumour partially cured bya natural reparative process of fibrosis, we have all sorts ofgradations to those tumours of such rapid growth and dis-semination that they merit the term " acute cancers." Theselast, fulminating in their progress, may produce a fatal issuewithin a few weeks of their commencement.

Third Scientific Report of the Imperial Cancer Research Fund.

It is always of importance to recognise any cancer promptlyand to operate promptly and as extensively as possible, nonatter how small or how slow in growing it may be, but inhese cases of acute mammary carcinoma prompt recognitionand immediate ,and extensive operation are absolutelyissential if any hopes of its cure are to be entertained. Most)f the current surgical text-books fail to make any reference

this particular class of cancers though they are a fairlyivell-denned class. That may be on account of the rarityofhe condition. During five years’ clinical and laboratoryinvestigation of cancer in London, in which time I mustGave examined some hundreds of cancers and other affections)f the breast, I encountered the condition on two occasions)nly, and in both cases the disease was considered to be ofan inflammatory nature by the surgeons who operated onthem. Speedy recrudescence and dissemination showed thetrue nature of the disease. In Glasgow I have seen fourcases and in Dundee one in the same number of years. Its

rarity in hospital practice may not, however, be a correctindication of the frequency of its occurrence in generalpractice.

Clinical characters. -Acute carcinoma presents itself as adiffuse swelling of the breast in which the normal shape ofthe organ is retained ; in fact, in comparing the two breastsone would be inclined to say that from an artistic point ofview the affected breast is the better modelled. There is no

flattening to be observed, no puckering even on digitalmovement, no asymmetrical bulging, no appearance as if ofa healed scar. The nipple may not be appreciably indrawnnor give any sero-sanguineous discharge. There may ormay not be a slight blush on the skin, especially in the lowerpart of the breast, but at any rate there is neither heightenedtemperature nor tenderness. Palpation of the breast showsthat the swelling is diffuse and that there is no localised

hardness, perhaps no hardness at all. The disease mayexist during pregnancy or lactation, and in these cases

is liable to escape detection, or it may be found at

any age, though generally it occurs in women who have notreached the period at which the occurrence of cancer

is most common. Thus it follows the broad law, towhich there are exceptions, that the younger the age ofthe patient the more rapid the growth. There are two

points in the diagnosis of the condition that are of greatvalue-the diffuse swelling like a hypertrophy and theoccurrence of pea1l d’orange-and the conjunction of thesetwo signs is pathognomonic. To the latter attention maybe more fully directed. The name pea1l d’orange is descrip-tive enough to one who has seen it, but to those who havenot noticed the condition it may not convey much impres-sion, for orange skin is very variable and the irregularpitting and puckering of the latter might very well describethe fairly common appearance of the skin in cancer of thebreast when it is affected by contraction of a growth under-neath. In acute carcinoma, on the other hand, the skin hasminute pits very regularly about a quarter of an inch apart(Fig. 1), giving the appearance as if the skin had beendabbed with a blunt pin. The term pig skin " is alsoapplied to it and is fairly descriptive ; it resembles pig’s skinif the hairs were removed and the pits represented by theplace of insertion of the hairs. But perhaps the best pictureof the condition is obtained by examining the back of thearm, especially when warm, under a fairly strong lens.

Cause of " peau d’orange."-The usually accepted opinion is-that the pitting is caused by the contraction of the fibroustissue in the tumour acting through the suspensory ligaments.of Astley Cooper. Fig. 2 shows one of these "ligaments"

"

or trabeculæ running to the corium through the interveningadipose tissue. It will be referred to later. Against thisview there are many objections. The Astley Cooper liga-ments are not so uniform in their arrangement, nor are theyso closely set in relation to each other as to produce by theircontraction such regular pitting. Again, any contractionfrom below would not produce depressions, the depth of whichis as great as, if not greater than, their breadth. We should

expect when we free the skin by dissecting under it that therewould be diminution in the depth of the pits, if they weredue to contraction from below. But the chief argumentagainst accepting the general view is that the condition isfound only in very rapidly growing, rapidly expandin.1/tumours, in which the fibrous tissue is at a min mum. Con-traction in less acute tumours produces a much rougherpuckering. A very suggestive clue to the real cause is givenby the appearance of the identical condition in the skin of

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the arm in the" brawny arm of breast cancer." Here thereare no "ligaments of Astley Cooper" nor any contractiondue to growth. The lymph stasis of I brawny arm " is due, not to the compression of the axillary veins, but to the

blockage of the lymphatics by the permeating growth. If any further proof were required for this it is supplied by thesuccess of Sampson Handley’s very ingenious operation oflymphangioplasty, which, by establishing artificial lym-phatics incapable of blockage, restores the lymph drainageof the arm. It might be permissible to conclude from theidentity of the two conditions that they were of similarcausation- lymph stasis ; but microscopic examination alonecan settle the question.Mieroseopio appearances of acute carcinoma.- Sections

taken from the tumour show large areas of spheroidal cellsclosely packed together and generally well preserved, thoughsometimes exhibiting central disintegrations. The appear-ance is sometimes called medullary" carcinoma. Thestroma is usually relatively small in amount. Portions maybe chosen from the growth which show only proliferationwithin the ducts and acini, but this proliferation is alwaysa marked feature and differs from that of mastitis, as I havepointed out elsewhere,2 in that there is no loss of nuclear

staining, whilst the cells tend to form numerous daughterlumina. At parts such as these, the elastic tissue sheath ofthe ducts is sometimes intact, at other parts it seems to beundergoing solution. This proliferation is found everywherethroughout the gland ; the epithelium of the whole organseems to be malignant. In addition, as we get nearer theedge of the growth, we find extensive lymphatic blocking bymasses of cancer cells. In Fig. 2 the trabecula runningfrom the mammary gland to the dermis through the inter-vening fat carries’ in its lymphatics epithelial cells in directcontinuity with those of the growth.

Appecunances of’ the skin.-When the skin is cut through itappears to be enormously thickened-from the normal0’5-1 millimetre over the breast to 8 millimetres or more.It is dense and white and appears like ordinary squamousepithelium much thickened, and it retains this appearance inalcohol. But the microscope shows that the epitheliumitself is thinner than usual. The normal papillae are to agreat extent obliterated or are only irregularly maintained.At some parts the papillary layers of elastic tissue are quiteabsent, at others they are dense, whilst intermediate condi-tions are found. Where they are absent the change seemsto be associated with the presence of collections of lympho-cytes and some plasma cells directly under the epithelium.The condition then resembles what has been described byRibbert, Victor Bonney, and others as tissue prepared forcancerous invasion by the epithelium. It may, however,here be noted that the surface epithelium is not proliferating,almost certainly never would do so, and it is probable thatthe so-called "precancerous" conditions are brought aboutby the same mechanism.The whole apparent thickening of the skin is due to the

condition of the corium. The connective tissue appears tobe in a sodden condition, the fibrous strands are widelyseparated from each other, the arterioles are dilated, andtheir walls are thickened. The lymph channels are espe-cially marked. Towards the deeper parts of the corium itwould seem as if practically every lymphatic channel werefilled with cancer cells ; some are filled right up to their

origin immediately under the epithelium, others as theyapproach the surface are seen to be empty and oftendilated. Perilymphatic collections of lymphocytes, witha few plasma cells amongst them, are marked features,

2 Archives of the Middlesex Hospital, vol. xiii.

DESCRIPTIONS OF ILLUSTRATIONS ON PAGE 862.FIG. 1.-Reproduction of a photograph of a breast with acutecarcinoma. Shows the peculiar pi’ting of the skin (peand’orange) characteristic of the disease. Case under thecare of Mr. David M. Greig.

FIG. 2.-Section of skin and underlying fat in acute mammarycarcinoma. A "ligament of Astley Cooper" is shown run-ning up to the dermis. The corium is much thickened.The black dots in the corium and in the ligament representmasses of cancer cells. The ltgament is the carrier of thelymphatic channels between mammary gland and skin.Projection drawing.

FIG. 3 -Projection drawing showing histological analysis ofthickened corium. Perilymphatic infiltration is marked atsome places, at ot hers absent. The elastic tissue under theepidermis is practically lost and the papilhe are to a greatextent flattened out.

and these perilymphatic infiltrations seem to follow a

definite plan. Fig. 3, which is a projection drawing,shows them running in a slanting direction from thesurface epithelium, and it is noteworthy that in thesection from which this drawing was taken they slopedtowards the trabecula shown in Fig. 2. It is probable thatthe lymphatics in this trabecula represent the trunk and thesmaller vessels in the cutis the branches of a lymphatictree. The cancer cells have permeated the lymphatics inthe opposite direction to the course of the lymph stream.In the centre of some of these perilymphatic infiltrations wemay see small masses of cancer cells in well-defined lymphaticspaces ; in some the channels are quite empty, whilst, on theother hand, we may find cancer cells in lymphatic channels,and even empty channels without any perilymphatic infil-tration. It is evident from this that the " round cell "

infiltration is not due to a reaction to the cancer cells assuch ; it may be present where these are absent or absentwhere these are present. In the former condition it

precedes the lymphatic permeation. Such infiltrationsseem to me to be the direct result of complete blockageof the channels, seeing that where we find them it is possibleto trace the empty channel back to a place where theepithelial cells are. When they are absent either aroundan empty or a filled lymphatic channel it is to my mind anevidence that collateral branches carry on the small amountof lymph circulation that is necessary as long as the surfaceepithelium can live. Small areas of round cell infiltrationcan also be seen round definite arterioles, but they are muchless marked.The depressions of the surface that give the appearance

of orange skin are the exaggerated pits of the hair follicles.The erector pilea has its fibres separated like the rest ofthe corium. To sum up, the thickening of the skin isdue to changes in the corium. These changes are theresults of lymphatic permeation and consequent lymphstasis. The corium is expanded and the overlying epitheliumis raised above its normal level by the pressure except atthose places where it is bound down by the insertion of a hairfollicle deep in the corium, where it is moored, as it were.

Taking into consideration the already known cause of thepitting in brawny arm and this same explanation advancedfor the similar condition, peau d’orange, in the breast, itseems reasonable to argue that where we get the condition itmust be due to lymph stasis caused by blockage of the

lymphatics. There is no disease of the breast at all likelyto produce this appearance other than cancer. Thus even inthe absence of other signs a diagnosis of acute mammarycancer from this alone would be practically certain.Dundee.

Clinical Notes :MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

A CASE OF GANGRENOUS FEMORAL HERNIA WITHSECONDARY RESECTION OF BOWEL AND

END-TO-END ANASTOMOSIS ;RECOVERY.

BY ROBERT D. MOTHERSOLE, M.D., M.S. LOND.,F.R.C.S. ENG.,

SENIOR HONORARY SURGEON TO THE BOLTON INFIRMARY.

THE patient was a married woman, aged 34 years, and wasadmitted to the Bolton Infirmary on March 9th, 1909, with ahistory of four days’ abdominal pain, vomiting, and absolute

constipation. On admission her abdomen was somewhatdistended, her temperature was 970 F., and her pulse-ratewas 122 ; she was found to have a strangulated femoralhernia on the right side. The sac when opened was seen tocontain foul pus and a knuckle of grey, gangrenous, smallintestine. The abdomen was opened by a second verticalincision to the outer side of the right rectus, its lowerend being an inch above Poupart’s ligament. The affectedloop was freed from the femoral ring and brought outsideand clamped; the gangrenous part was then excised anda Paul’s tube was tied into each end. An indiarubberdrainage-tube was passed into the pelvis through the femoral