NODULAR INDURATION AND SHRIVELLING OF THE MAMMA FROM MASTITIS.
The descriptions of this affection are so various, and in part so general, that we can scarcely form an exact picture of it. At one time it is the pain, then the atrophy, then the nodular formations, then the diffuse indurations (with or without retention cysts), then the results of long continued irritations, then the inactivity of the gland, which is made more or less of in the descriptions of this affection. The names, too, which are given to this rare affection of the breast, are various, so that it is a matter of doubt as to whether the different authors have been describing the same affection: fibroma mammas diffusum, elephantiasis mammas dura, induratio benigna, cirrhosis mammas, corps fibreux, mastitis interstitialis diffuse et circumscripta.
As to the anatomical genesis of the process there is no difference of opinion. It does not consist in simple atrophy of the glandular tissue with more or less fatty degeneration of the connective tissue, since this would only show normal involution, and would only attract attention if this atrophy and its partial reparation proceeded at intervals in single portions of the gland. The process under consideration leads much more to partial or total indurations, which may eventually terminate in retrac tion of the tissue, and even of the nipple and skin. But the tissue of the remaining indurations is not loose, senile connective tissue, but con forms to the character of hard cicatricial tissue, and appears to retain this character, never becoming soft and tendinous, as cicatricial tissue some times does. Any competent judge must conclude, even though he has not observed the different stages of this process, that it begins with small-celled infiltration of the connective tissue, and must therefore be regarded, morphologically at least, as a chronic inflammatory condition. We must, then, consider how the epithelial elements of the gland behave. How difficult it is to differentiate this from carcinoma mammas cicatricans, is well known by all who have given any attention to this subject. It is therefore no reflection, when we say that the descriptions of disputed subjects examined by the older methods—for example, the descriptions of Wernher—are, in spite of their fullness, not satisfactory. In the case pic tured and described by KiMig, there was, at all events, great dilatation of the acini and excretory ducts, with hard, fibrous, interstitial tissue; nevertheless, such involution-cysts are not so seldom found in carcinoma of the breast and also in senile breasts, without induration of the tissue.
In the present state of opinion regarding carcinoma, it would be admissi ble to consider such cases as healed or healing carcinomata. So long as the opinion, " Because the disease has neither re-appeared locally nor elsewhere in the body, it cannot be of a cancerous nature," was held, the matter was a very simple one; but as we now no longer believe in this dogma, only an exact, anatomical, differential diagnosis can decide.
Unfortunately I cannot offer anything to aid in the diagnosis. In the anatomical examinations which I have made on this subject, sufficient analyses with modern methods have always shown it to be carcinoma. I was very much disposed to doubt the existence of a chronic mastitis ending with cicatricial shrinking (though I did not entirely disbelieve in it), when a short time ago I had a patient in whom there was a condition of the left breast which was without doubt what I had until then sought for in vain. A. M. W., a farmer's wife; 45 years old, always healthy; always menstruated regularly; had borne nine children, the first fifteen years, the last two and one-half years ago. She had nursed all the children at both breasts, usually for sixteen months, and had never had a bad breast.
(Unfortunately no mention was made in the history as to whether men struation had ceased at the time or not.) While nursing her youngest child, which was born November 3, 1878, she noticed that a spot as large as a nut and above the nipple of the left breast was becoming hard; this in duration constantly increased, particularly after the cessation of lactation. Depressions formed and gradually the gland atrophied, as shown in the illustration. The right breast, which was well-developed, remained abso lutely unchanged. There had been no pain during the whole process, and even at this time palpation was not painful. The axillary glands could not be felt. The atrophied gland was freely movable over the pec toralis major muscle: its consistence was that of a moderately firm cicatrix though not so firm as a scirrhus. There were no indurated nodules to be found in the degenerated organ.