CHRONIC MASTITIS.—COLD ABSCESS.—TUBERCULOSIS.—SY PHILIS.—INDURATION THE RESULT OF CICATRICIAL RETRACTION.
When there appears near or under the gland a painless, slightly movable induration which finally, with or without early redden ing of the skin, softens, it is far more probable that it is connected with some chronic inflammatory process of the ribs than with the gland. Cold abscesses in the mammary glands before puberty are never seen. After puberty they affect married as well as unmarried women, and particularly those of a scrofulous or tuberculous diathesis. An encapsulated extravasa tion of blood, following a blow, may also form a cold abscess. In most of the cases hitherto observed, the induration began in single lobules of the glands without any known cause, and the most varied interpretation may be given to such induratious. In many cases, the diagnosis can only be made after long observation. I have very recently seen cases of cold ab scesses, which have been described by H. Klotz (Arch. .f. Iil. Chir. Bd. XXV). In other countries these cases seem to be more frequent. Erich sen, indeed, describes two forms: chronic diffuse abscess and chronic encysted abscess. The first form is seen in persons of all ages, married and unmarried, of scrofulous diathesis, and develops in the cellular tissue behind the mammie. (These are probably cold abscesses, which arise from some disease of the ribs). The second form is of especial impor tance because it is with difficulty differentiated from tumors of the breast, and since on this account many unnecessary amputations have been done. These abscesses develop almost exclusively after confinement or abortion; they are indolent, indurate slowly, and after the lapse of months gradually soften in the centre. Retraction of the nipple is a result of this, and usually there is some oedema over the swelling. The diagnosis can only be made after lengthy observation, and, at times, only by puncture. The treatment consists of puncture, drainage and compression. Samuel Gross also mentions the difficulty of diagnosis, and lie has seen the affec tion in unmarried, scrofulous girls, but more often as a result of a sub acute or chronic mastitis in women who had been confined, and especially in that breast to which the child had not been placed.
Tuberculosis of the Breast.—All authors agree that true miliary tuberculosis of the breast does not occur, or that up to the present time at least it has not been observed. Kolessuikow (Arch. f Path. Anal., Bd. 70) describes a form of necrosing interstitial mastitis occurring in cows, in which there is a growth of giant cells as in true tubercle. What Cooper and others, especially English authors, describe as " scrofulous tumors of the breast," is not sufficiently clear in order to draw conclusions as to the anatomical structure of these indurations. Velpeau speaks of
tubercles in the skin of the mammEe (probably disseminated carcinomatous nodules) and of fibro-tuberculous nodules (not clear) in the substance of the gland. While I was assistant in B. von Langenbeck's clinic there was there for a long time a young, blonde, well-nourished girl of decidedly scrofulous habit, who had in one breast several nodules as large as a hazel nut or walnut, which contained a yellow, cheesy pus; the affection was diagnosticated as tuberculosis of the mamma, and was cured by incision of the single foci and cauterization with nitrate of silver. I would designate this, according to the present nomenclature, as caseous, chronic lobular mastitis, without being able to say anything as to its cause (whether due to scrofula or syphilis); I have never seen a case similar to it since, and, so far as I know, no anatomical investigations of such cases have been made. Through one of my assistants, I was enabled to observe the following case: Mrs. A. II., 26 years old, came under treatment for pulmonary tuberculosis on August 23, and died three days later. The patient had never complained of the mamma; there was scarcely any noticeable swelling thereof, and therefore no mention of it was made in the patient's history. The diagnosis made after the autopsy was: chronic tuberculosis of both lungs, with phthisis of both upper lobes; tuberculous ulcer of the large intestine; tuberculosis of the right mammary gland. In the history of the patient it is stated " Both mamma] were very much withered, small, their skin wrinkled, nowhere excoriated or ulcerated. Nipples and areolm were darkly-pigmented. Thl right mamma was some what larger than the left, and contained a disc-like body about 4 inches wide and f inches thick, having a nodular feel externally. The left mamma was uniformly soft and spongy. Section showed the right mamma studded with foci filled with caseous, crumbling masses, containing hero and there a tuberculo-purulent fluid in the centre, besides small caseous foci as large as a hemp seed." The microscopic sections, made from the walls of the larger foci, were not sufficiently clear to draw conclusions from; the very atrophic glandu lar elements were hardly perceptible, and the tissue was so clouded with a finely granular detritus strewn between the fibres, that J cannot say anything certain concerning the probable presence of giant cells in the boundary layers of the caseated foci. At any rate, the anatomical de scription leaves no doubt but that here was a rare case of true tuberculosis 3 of the breast. It is unfortunate that the other (left) apparently healthy gland was not examined, as it is possible that the first stage of this pro cess might have been found there.