THE MAMMARY GLAND 1435 



may become cystic. The nipple may suffer from epithelioma, myoma, myxoma, angioma, papil- 

 loma, or fibroma. The innocent tumors of the breast are fibroadenoma, cystic adenoma, myxoma, 

 and angioma. The skin of the breast may suffer from any form of growth or cyst which could 

 arise from the skin of another part. Malignant tumors of the glandular structure are ten times 

 as frequent as innocent tumors. Sarcoma is rare; carcinoma is very common. 



Carcinoma of the breast has occupied much of the attention of surgeons during recent years. 

 The old operation was uniformly followed by recurrence. The modern radical operation has 

 been evolved from the studies of Moore, the younger Gross, Heidenhain, Stiles, Banks, Halsted. 

 and others. The modern operation always removes at least the skin and subcutaneous tissue 

 over the hemispherical portion of the breast, the outlying lobules of the breast, the pectoral fascia, 

 and the sternal portion of the great Pectoral muscle, the lymphatic tracts from the breast, the 

 lymphatic nodes and cellular tissue from the axilla, and from beneath the Latissimus dorsi 

 muscle. The pectoral fascia and the sternal portion of the great Pectoral muscle must come away 

 in every case, because breast tissue may pass through the fascia. The entire breast must be re- 

 moved, because even in a recent case the entire breast is regarded 'as infected. The clavicular 

 portion of the great Pectoral muscle is anatomically distinct from the sternal portion and its 

 removal is not imperative. Some operators remove the lesser Pectoral muscle. To leave it is 

 of no value to the arm, and it frequently causes an annoying rigid band anterior to the axilla. To 

 take it away gives ready access to the axillary vessels at a desirable point above. The sheath of 

 the axillary vein should be removed with the nodes and cellular tissue of the axilla. The nodes 

 receiving lymph from the cancerous area must be removed, of course. In view of the fact that in 

 an undetermined percentage of cases a lymph tract passes direct to the subclavian nodes, it is 

 evident that these nodes may become infected by this route instead of, as is more usual, secondarily 

 to axillary infection ; hence it seems wiser in every case to remove the cellular tissue and nodes 

 from the subclavian triangle. All of these structures should be removed as one piece, in order 

 to avoid cutting across lymph tracts and flooding the wound with carcinoma cells which might 

 adhere, grow, and reproduce cancer. 



Halsted's operation is the method adopted by most surgeons. The wound cannot be com- 

 pletely closed, and the raw spot is covered at once or later with Thiersch's skin grafts. (For 

 surgical considerations regarding the lymphatics in mammary carcinoma see page 89^7 



a ^J 



The male breast (mamma virilis) is a small, flat structure, consisting chiefly 



of connective tissue, but containing some branched tubules. Under normal 

 circumstances it remains permanently of the infantile type. It possesses a nipple 

 which is much smaller than that of the female breast, and which usually lies 

 over the fourth intercostal space, but may lie over the fourth or fifth rib. The 

 nipples of the two sides are rarely placed quite symmetrically. Accessory glands 

 and accessory nipples are as common among males as females. The male 

 breast may exhibit some evidence of temporary functional activity at birth and 

 at puberty. Cases have been recorded of actual lactation by the male breast. 



Applied Anatomy. The male breasts may undergo enormous hypertrophy (gynecomazia) . 

 In these cases the penis is often small and the testicles may be atrophied. The breasts may be 

 absent in the male. Disease of the male breast is not nearly so frequent as disease of the female 

 breast. The organ may be the seat of syphilis, tuberculosis, acute or chronic mastitis, abscess 

 or tumor. A number of cases of cancer of the male breast have been recorded. 



