Text Appearing Before Image: It is important to remember that a very small and freely movable massin the breast is not incompatible with early and widespread metastasis (see chapter onprognosis). Operation is not only futile in cases of this kind but, as explained above, isinstrumental in a definite proportion of cases in hastening the death of the patient. CARCINOMA 569 It is not an easy matter in all instances to decide whether a chronic cough is due to along-standing bronchitis or to cancerous involvement of the pleura and lungs. It islikewise difficult to determine the cause of dyspnea in a patient with a cancerous tumorof the breast. Asthmatic attacks are sometimes caused by the pressure of cancerinvaded peri-bronchial lymph nodes on the bronchi; more often these attacks are merelyincidental and have nothing to do with the malignant process in the breast. Thedifferentiation of rales due to inflammatory disease of the lungs from those dependingupon metastatic cancer nodes may sometimes be made by the X-rays. Text Appearing After Image: Fig. 200.—Ulcerating mammary carcinoma of the medullary variety. Inoperable. Small amounts of pleural effusion or ascites at once suggest the probability of metas-tasis to the pleural or peritoneal membranes, but it must be remembered that theiroccurrence in a patient suffering from mammary cancer is by no means conclusive oftheir carcinomatous origin. Not infrequently masses of cancerous tissue are palpablein the pelves of women with a primary mammary growth. It is not unusual, how-ever, for a pelvic tumor to occur independently of the growth in the breast so that themere finding of a mass in this situation is not a positive contra-indication against opera-tion. Paget found that mammary cancer is frequently associated with fibroid tumorsof the uterus. Therefore, while it is advisable to examine the pelvic viscera, as aroutine measure, in patients with malignant tumors of the breast, we must not concludethat every mass found during the course of such examinations, is a metastatic gr
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