Copyright
Greensboro College.

Southern medicine and surgery [serial] (Volume 106 (1944)) online

. (page 83 of 98)
Online LibraryGreensboro CollegeSouthern medicine and surgery [serial] (Volume 106 (1944)) → online text (page 83 of 98)
Font size
QR-code for this ebook


mercial fertilizers and using a natural manure and follow-
ing that applying humus to the soil, the sterility of cattle
was reduced from 28 per cent to 2 per cent.



November, 1944



SOUTHERN MEDICINE & SURGERY



i he Interpretation and Treatment of the Discharging

Breast*

J. D. Gilland, M.D., Charlotte



THIS SUBJECT is chosen for the reason that too
often this clinico-pathological syndrome is very
perplexing. To intelligently interpret, evaluate and
lay out a plan of therapy, its clinical significance
must be clearly understood. Discharge is well rec-
ognized as indicative of morbid changes within the
ductile and secretory systems of the breast, but it
affords in itself scant information concerning the
provocative factor. The heads of clinics, who see
large numbers of breast cases and are able to draw
statistical conclusions, vary so in their statistics
and express opinions so diverse as to be matched
by few other clinical problems. A discharge from
the nipple of a non-lactating breast is frequently
the initial sign which impels the patient to seek
medical advice. No one has claimed, except in the
rare cases of true vicarious menstruation, that
bleeding can come from a healthy breast.

Incidence: In 8 per cent of all mammary lesions,
some type of discharge occurs from the nipple — a
sanguinous discharge in 6 per cent. Of early signs
of cancer of the breast discharge from the nipple
is second only to the presence of a lump. It is the
first sign in 1 per cent of all breast cancers, and
4 per cent of breast cancers discharge. Bleeding
from the nipple occurs with equal frequency in
malignant and benign conditions. One-half of be-
nign tumors, having a discharge, are papilloma-
tous; 47 per cent of duct papillomata discharge
blood. There is a discharge in 7 to 15 per cent of
cases of chronic cystic mastitis. The incidence of
mammary cancer is only 9 per cent in cases of dis-
charge from the nipple, without, a palpable mass;
75 per cent of discharges are due to three lesions —
cancer, chronic cystic mastitis and ductal papil-
loma. The papilloma and chronic cystic mastitis
with epithelial hyperplasia is regarded as precan-
cerous. The age at which bleeding occurs in the
malignant cases is about that of the usual appear-
ance of cancer. As far as can be determined, there
is no indication that having nursed predisposes to
bleeding breasts, malignant or benign.

Types of Discharge: The amount, color, consist-
ency and odor of the discharge depend on the na-
ture of the causative lesion and the degree to which
the secretion is altered before reaching the surface
of the nipple. If bleeding arises near the orifice
of a duct, the escaping fluid is frankly hemor-

td to Tri-State Medical Association of the Carolinas ai



rhagic; but if the site is deep within the matrix,
the fluid may assume a serosanguinous or a serous
character or even a brownish chocolate color, due
to the degeneration of the retained blood and its
admixture with other secretions from the duct.
The character of the discharge may also be altered
by infection or necrosis.

Blood is discharged in such a variety of patholo-
gic conditions in the breast as to possess little
diagnostic value. In the absence of trauma or a
palpable tumor, it is most likely to be caused by
a papilloma of the duct. It is imperative that the
primary cause be determined. The bloody dis-
charge may be of traumatic origin, and if so, is
easily recognized by the history and on examina-
tion there may be evidence of ecchymoses. Carci-
noma cannot be excluded because the discharge is
free of blood. In only half such cases is the dis-
charge bloody.

A serous discharge from the nipple is, in too
many cases, regarded as inconsequential. A thin,
clear, straw-colored fluid escapes from the breast
in 10 per cent of all cases of sarcoma; in many
cases of carcinoma. Early the discharge may be
serous, and as degenerative changes occur it be-
come hemorrhagic. A mammary cancer may pro-
duce a serohemorrhagic discharge from one duct
and a serous discharge from an adjacent duct. A
serous discharge is seldom a feature of papilloma.
Serous fluid comprises 22 per cent of all discharges.

A thick, greenish-yellow discharge from the nip-
ple, usually bi'al '. does not discharge itself

spontaneously, .-<i is caused by the retention of
secretion in dilated ducts following lactation. A
mild secondary infection combined with the degen-
erative products of desquamation may account for
the color of the discharge.

Occasionally a whitish discharge will seep from
the nipples of the newborn, in which instance both
breasts are hypertrophied, tense and tender. All
symptoms subside spontaneously within two or
three days. Sometimes a milky fluid escapes from
virginal breasts during pregnancy. Retarded post-
lactation involution may cause a spontaneous leak-
age of milk for several months after active nursing
has been discontinued. The discharge may contain
pus, or in rare cases, masses of desquamated epi-
thelial cells.

id Virginia, meeting at Charlotte, Feb. 28th-29th, 1944.



THE DISCHARGING BREAST— Gilland



November, 1944



Etiology of Discharge: The three most common
causes of discharge from the breast are duct pa-
pilloma, carcinoma and chronic cystic mastitis, in
that order of frequency. Other causative factors:
non-specific infection of dilated ducts, endocrine
factors (as yet unconfirmed), trauma, sarcoma,
fibroadenoma, luetic mastitis, tuberculous mastitis,
Paget's disease of the nipple, inflammatory cysts
and fibrous mastitis.

Examination of the Breast: Inspect and palpate
in the upright and the supine position; palpate be-
tween the hand and chest wall, between the two
hands, and between the thumb and fingers. In
spite of the accessibility of the mammary gland,
few small infiltrating carcinomata, papillomata,
dilated lactiferous ducts or compressible cysts can
be palpated. The presence of a small lesion, such
as a papilloma, is occasionally demonstrated by the
positive pressure test, whereby pressure over a
constant segment within or near the areolar border
or in the periphery of the breast causes a discharge
to emit from the nipple.

Transillumination will distinguish between a
solid tumor and a cyst containing clear fluid, and
will often reveal impalpable papilloma which may
be multiple. The character of the opacity does not
diefferentiate between benign and malignant tu-
mors. Blood is intensely opaque. The most striking
feature of transillumination of the normal breast
is the prominence of the blood vessels. If the pa-
pilloma has not bled it may escape detection, as
opacity is usually due to the collection of blood
about it. It is important to emphasize that minute
papillomata may fail to cast shadows, even when
the intensity of the light is reduced to a minimum.
Soft-tissue rontgcnography has failed to clearly
depict the identifying characteristics of mammary
neoplasms. All pathologic conditions with a dis-
charge from the breast must originate within or
secondarily involve the ductile system. Any proce-
dure, therefore, which visualizes the lactiferous
ducts should possess diagnostic value. A technic of
contrast rontgenograms has been developed. A
radiopaque material, such as stabilized thorium
dioxide, is introduced into the milk ducts by can-
nulating their orifices with a blunt 26-gauge nee-
dle. By use of stereoscopic rontgenograms an alter-
ation in the size, shape or conformation of these
ducts can be detected readily and the causative
agent identified. The possibility of serious tissue
reactions to the radiopaque material, plus the pos-
sibilities of diagnostic error, minimize the value of
mammographic studies.

Microscopic examination of the discharge is
often necessary in order to demonstrate the pres-
ence of blood, but is of no help in revealing the
presence of malignant cells. The attempt to diag-



nose a carcinoma under these circumstances re-
quires a special knowledge of the differentiation of
morphological appearances of benign, inflamed and
atypical epithelial cells, from those definitely ma-
lignant. The absence of malignant epithelial cells
does not negative the diagnosis.

Frozen-section diagnosis of lesions manifesting
a nipple discharge is sometimes difficult, because
early or uncommon types of cancer may be encoun-
tered for the diagnosis of which permanent sections
may be necessary. Upon the microscopic study of
the cells of the lesion the final diagnosis is ob-
tained. It is on this diagnosis that additional sur-
gery may be done, radiation therapy instituted,
and the prognosis given.

Interpretation: Unless there are contraindica-
tions, every benign tumor should be removed, lest
it become malignant. In any case of tumor with
bleeding, surgery should be adopted to reach a
diagnosis, and a local or radical excision carried
out accordingly. It is important to realize that
bleeding from such a tumor is not even presump-
tive evidence that it is malignant. Bleeding should
not stampede one into a radical operation; a com-
plete mastectomy, even, is not indicated unless
there are multiple lesions or other conditions which
would, without discharge, indicate mastectomy.
Any woman who has had a local operation for a
condition presenting a discharge should be watch-
ed with extra care at more frequent intervals than
usual; for we know that multiple lesions may and
do exist and the lesion previously excised may not
be the one responsible for the discharge. Repetition
of the discharge demands careful consideration of
more extensive removal. In discharging breasts
with no demonstrable tumor, it is exceedingly dif-
ficult to determine the best procedure. The unnec-
essary removal of a breast is a calamity. Some
students of this question, however, hold the opinion
that bleeding from the breast is an exceedingly
grave symptom, often demanding operative inter-
ference. To await the clinical detection of a gross
lesion may spell the difference between a prevent-
ed or cured malignant growth, and the palliative
removal of a malignant breast. When a tumor can-
not be demonstrated by any method, the proper
safeguard will usually be removal of the entire
breast. Papilloma may be single, or multiple (30%
of cases) ; and, when multiple, they may be found
in separate ducts. A papilloma may become malig-
nant: the majority of papillary carcinomata are
thought to represent a late development in pre-
existing benign papillomata. The carcinomata as-
sociated with nipple discharge are often the more
localized, slowly-growing papillary or comedo
types. One never knows from a clinical examination
whether there is only one papilloma or many pa-



November, 1944



THE DISCHARGING BREAST— Gilland



pillomata, or whether there is or is not a carci-
noma. These matters cannot be decided by any-
thing else than a careful examination with many
microscopic sections of the whole breast.

Therapy: The method of treatment in cases of
discharging breast must be influenced by the num-
ber of cases of cancer of the breast in which a
discharge occurs, and upon the incidence of ma-
lignancy which ultimately follows such a sign. In-
dividualization in therapy is one of the secrets of
success in the handling of breast cases. The case
in which both tumor and discharge are present
arouses no controversy. The presence of the mass
is an indication for surgery, independent of dis-
charge. The troublesome and dangerous problem is
the discharging breast which, on examination, con-
tains no mass. The surgeon should offer no apology
for performing many biopsies and, finally, simple
mastectomy rather than local excision in border-
line cases, where the picture suggests the possibil-
ity of carcinoma. However, the psychic and cos-
metic arguments against mastectomy are prominent
in the minds of patients, and demand considera-
tion. There are both operative and non-operative
forms of therapy, each adequate in specific cases.

Operative — 1. When transillumination demon-
strates an area of opacity in one of the large ducts
near the nipple, the diagnosis of probable papil-
loma may be made. Local excision of the offending
duct is indicated. A technic that is satisfactory for
identifying the diseased duct is that of canalizing
with a blunt needle or probe the duct orifice from
which the- discharge may be expressed. An incision
is then made at the areolar border and the duct is
distinguished by tilting the inserted needle. The
offending duct is thus removed.

2. In those cases exhibiting a positive pressure
sign, a local excision of the duct or a block ex-
cision of a segment should be done.

3. Breasts exhibiting a localized nodularity
should have quadrant excision or a simple mas-
tectomy.

4. Breasts manifesting a generalized nodularity
should have a simple mastectomy. Localized or
diffuse "shottiness" is apt to present a picture of
epithelial overgrowth — potentially malignant.

5. In case of discharge after the menopause, the
psychic and cosmetic arguments against mastec-
tomy are so weakened, and the threat of cancer so
real, it is safer to do a simple mastectomy, unless
some definite local lesion can bo identified.

6. One should not hesitate to advise and per-
form a simple mastectomy for continued bleeding
of undetermined origin of one month or more.

Non-operative: It must be borne in mind that
all cases treated medically are done so empirically,
without a definite diagnosis.



1. Radiation of the discharging breast will stop
the discharge in half the cases; but in some, cessa-
tion is only temporary.

2. Dilatation of the duct with the injection of
sclerosing solutions has been tried, and, while the
discharge may cease, such a procedure is not rec-
ommended.

3. Good results have been obtained after estro-
gen therapy in some women in whose breast bleed-
ing occurred at the time of the menopause. This
postulates a lobular proliferation of epithelium due
to a deranged hormonal physiology, and has clini-
cal and experimental evidence in support. The
therapy rests upon the clinical diagnosis, and the
clinical diagnosis in this age-group is not to be
relied upon to this extent.

4. If trauma is established beyond all doubt to
be the etiological factor, leave the breast alone and
the hemorrhage will stop.

5. Observation may be the treatment of choice
■ — the facts in each case to be carefully analyzed.

Further aids in individualizing patients with a
breast discharge as to surgery may be had from a
consideration of the following facts: (1) the age
of the patient; (2) the duration of the discharge;
(3) the type of discharge; (4) a family history of
cancer; (5) the size of the breast; (6) the psy-
chology of the patient, and (7) the question of an
adequate follow-up, essential to a program of ob-
servation. Errors in treatment may be avoided if
exploration be instituted, and the most suspicious
zone excised and examined microscopically. A dis-
charge from the nipple with or without a palpable
tumor is a surgical condition.

Summary

1. A discharge from the nipple of a non-lacting
breast is a warning sign of exceedingly grave sig-
nificance.

2. A discharge occurs from the breast in equal
proportions in benign and malignant conditions.

3. Seventy-five per cent of such discharges are
due to three lesions: cancer, chronic cystic mastitis
and ductal papilloma. The papilloma and chronic
cystic mastitis, with epithelial hyperplasia, are re-
garded as precancerous.

4. The character of the discharge cannot be re-
lied upon to identify the underlying etiologic fac-
tor.

5. Given a case of a discharging breast, every
effort should be made to arrive at a definite diag-
nosis, using any or all of our means of physical
examination.

6. Interpretation of this important sign revolves
aboul the presence or absence of a demonstrable
mass.

7. In discharging breasts in which a mass is de-
tected, the treatment is of the mass and not the



THE DISCHARGING BREAST— Gittand



November, 1944



discharge, and should be the removal of the tume-
faction for histological study. The differential diag-
nosis must be made with a microscope. Excised
tissue is always sent to a pathologist. Should ma-
lignancy be encountered, radical treatment is in-
stituted at once.

8. Various forms of therapy are presented for
the handling of those cases in which no tumefaction
is detected.

Conclusions
In the light of all that has been said, I feel that
it is imperative in protracted discharge from the
nipple, either continuous or intermittent, regardless
of its character and regardless of whether a tumor
is demonstrable, be given serious consideration;
and that, in most instances, the bleeding tissue be
removed, in order that the exact nature of the le-
sion may be determined. If a palpable tumor is
present, a local excision may suffice. If several
tumors or diffuse thickening can be felt, or if no
tumor can be demonstrated, the entire breast
should be removed. All cases, no matter how treat-
ed, should be watched with unusual care. Impor-
tant cancer-preventive surgery can and should be
performed and the surgeon will occasionally be re-
warded by the discovery of an early, impalpable
cancer.

Case History

A 40-year-old colored woman, admitted to Good Samar-
itan Hospital, Charlotte, on October 19th, 1943.

C. C. Bleeding from the left breast.

P. I. On October 17th, two days prior to admission,
patient first noticed a soreness in the left breast, and on
that date blood was expressed from the nipple. The pa-
tient attributes her present illness to the lid of a victrola
falling on her left breast last summer (1943), after which
the breast was sore for two weeks.

Patient has had 12 pregnancies, has 12 children, the baby
being 18 months of age. One menstruation has occurred
since last delivery.

T. P. R.— Normal. B. P. 130/82, middle-aged, very
obese, seemingly in good health and free of distress.

Both breasts are very large, pendulous, symmetrical.
Right: Non-tender, normal to palpation, no masses. Left:
No definite mass palpated, though there is a sense or feel
of increased nodularity throughout. An area of tenderness
is present mesial to the nipple and pressure on this area
causes a small amount of dark reddish-brown fluid to be
extruded from the nipple. No glands palpable beyond the
breast.

No specific diagnosis but this onset of bleeding consid-
ered a warning sign of grave significance.-

I had the choice of three courses —

1. Observation — considered unwise.

2. Local excision — of the segment mesial to the nipple —
considered inadequate, because of inability to obtain a
frozen section at this hospital and so follow through with
a more radical operation, if malignancy were reported.

3. Mastectomy — which was done. A left simple mastec-
tomy was performed on October 20th. A simple, rather
than a radical, operation because of hesitancy to do a
radical without a positive pathological report of a malig-
nancy and if it was malignant, it was an early malignancy.



It was about a foot away from the chest wall and a simple
mastectomy should thus suffice. Mastectomy was decided
on because:

1. I considered the percentage incidence in favor of
malignancy.

2. If it was malignant, it was an early lesion and I
could probably effect a cure.

3. If it was benign, the patient had lost little compared
to what she would gain if it was malignant.

4. The breast would probably never be used again func-
tionally.

5. If I had done some other procedure, and the lesion
had been malignant, the patient may have succumbed to a
cancer death in a few years, and there would then be 12
little motherless Negro children.

Pathological Report: "Involuting breast with atypical
glandular and ductal epithelium with hemorrhage at nip-
ple. The case is to be looked upon as a border-line case.
The epithelial hyperplasia is intraductal." — Dr. Paul Kim-
melstiel.

The patient left the hospital on the 9th day, post-opera-
tive, in good general condition. The incision had healed by
primary union.

Bibliography

1. Adair, F. E.: Sanguineous Discharge from the Nipple,
Relation to Cancer of the Breast. Ann. Surg., 91:197,
1930.

2. Bascock, W. W.: A Simple Operation for the Dis-
charging Nipple. Surgery, 4:914, 1938.

3. Chaetie, G. L., & Cutler, Max: Tumors of the
Breast. J. B. Lippincott Co., Philadelphia, 1931.

4. Cutler, Max: Transillumination as an Aid in the
Diagnosis of Breast Lesions. S., G. Gr 0., 4S:721, 1929.

5. Davidoff, R. B., & Friedman, H. F.: The Treatment
of Discharge from the Nipple. New Eng. J. of M.,
216:1072, 1937.

6. Geschichter, C. F.: Diseases of the Breast. J. B. Lip-
pincott Co., Philadelphia, 1943.

7. Gray, H. K., & Wood, G. A.: Significance of Mam-
mary Discharge in Cases of Papilloma of the Breast.
Arch. Surg., 42:203, 1941.

8. Hicken, N. F., Best, R. R., & Hunt, H. B.: Dis-
charges from the Nipple. Arch. Surg., 35:1079, 1937.

9. Hichey, P. R.: Nipple Discharge. Ann. Surg., 113:341,
1941.

10. Miller, E. M., &- Lewis, D.: The Significance of a
Serohemorrhagic Discharge from the Nipple. J. A. M.
A., 8:1651, 1923.

11. Petersen, H. A.: Benign Tumors of the Breast. /.
Nat. Med. Assn., 33:4:113.

12. Stowers, J. E.: The Significance of Bleeding or Dis-
charge from the Nipple. 5., G. & O., 61:537, 1935.

13. Wainwright, J. M.: The Treatment of the Bleeding
Breast. Amer. J. Cancer, 19:339, 1933.

Discussion
Dr. A. E. Baker, Charleston: Discharges from the nip-
ple are associated with a variety of breast conditions.
Some are serous or milky discharges, others bloody or
sanguinous. The milky secretions are caused by an irregu-
larity or impairment in the endocrine system of which the
pituitary gland and the ovaries play the leading part, as
they do in the function of the normal breast from time of
birth. One-tenth of the newborn babies develop enlarged
secreting breasts because of maternal hormones born in
them. Shortly these breasts subside and remain dormant
until puberty, when the gonads mature and their own en- •
docrine secretions are established. The breasts then enlarge
and remain so until menopause when the gonads atrophy,
and so do the breasts. This is nature's plan.
GILLAND— To P. 442



November, 1944



THE DISCHARGING BREAST— Gilland



CLINIC

Conducted by

Frederick R. Taylor, B.S., M.D., F.A.C P.,
High Point, N. C.

A 34-vear-old looper complained of soreness in
the right lower quadrant of the abdomen and nau-
sea, on Aug. 8th, 1942. She stated she had had
trouble with pus in her kidneys for about 9 years,
for which a physician had treated her off and on.
At the onset of this trouble she began having pel-
vic pains on both sides, no worse on voiding.
Though they kept up for 2 weeks, she paid no
attention to them, though for the last 3 or 4 days
of this 2-w T eeks period she had fever and vomited
every time she ate. She did not have a doctor at
this time. At the end of this 2-weeks period she
went to bed one night and her husband said she
raved all night, though she remembers little about
it. A physician, called at 3:00 a. m., told her she
had "poisoned kidneys." He gave her medicine,
but she remembers nothing of the next 4 days.
She stayed in bed at home for 6 to 8 weeks. Then
she seemed to get all right for awhile, but later
her trouble kept recurring. After going to the same
physician off and on for about 8 years, she devel-
oped gross hematuria for the first time, and having
heard that Dr. E. A. Sumner was especially good
at urology, just about this time she consulted Dr.
Sumner, who made pyelograms, gave her cysto-
scopy treatments, etc., and she improved the most
she had done since the onset of her trouble. She
last saw him 3 or 4 weeks before consulting me,
just before he left to go into military service. He
told her she was doing well then, and she was feel-
ing pretty well, but the week she came to me her
old symptoms of bilateral pelvic pain, right-sided
lumbar pain and nausea returned. She has not
vomited this time. At times she has noted pitting
edema of her feet and swelling of her face. No
headache. There is discomfort on voiding, though
it is hard for her to say whether it hurts or burns.
She has no frequency now, but some urgency. It
is very difficult at times for her to void at all.
She had a surgical menopause in 1937 because of
continuous menstruation. Her appendix, right
ovary and uterus were removed.

She had tvphoid fever in childhood, pneumonia



Online LibraryGreensboro CollegeSouthern medicine and surgery [serial] (Volume 106 (1944)) → online text (page 83 of 98)