From my observation of this case, which was not examined anatomi cally and which does not coincide with the descriptions of other authors, I do not think that I am entitled to give a general judgment on chronic atrophic mastitis, and so much the less as in this case two of the symp toms mentioned by all authors, pain and induration, were entirely absent. As concerns the treatise of Wernher, after re-reading it, I have the same opinion that I had when I first studied it twenty-five years ago. Should we admit that Wernher had something special in view, most modern his tologists would recognize in the accurate descriptions typical forms of atrophying cancer of the mamma. What Wernher understands by atro phying sarcoma does not correspond to the modern view of sarcoma estab lished by Virchow and myself. Whether Virchow has ever seen a case of chronic interstitial mastitis with atrophy during life, and then made an anatomical examination of it, does not appear from his statement. From all this we must understand that the process is by no means frequent, nor does it appear in various forms, with different symptoms. We know nothing as to the causes, except that it appears certain that the affection is much more frequent in women between forty and fifty years old, who have borne children and liave nursed them.
With the as yet uncertain diagnosis, it is advisable not to delay opera tive measures too long. All observations show that the intense shoot ing pains, by which the patients are usually made miserable, can be removed in no other way, and that there are certainly no means of bring ing the process to a stand-still. If the case be so simple and so clear as the one seen by me, and there are no pains, we should not think of operating.
The presence of chalky concretions in the mamma is extremely rare, especially so if we except bone-formation in chondromata, as is tolerably frequent in bitches but is seldom seen in man. Gross saw, in two cases, irregular, roundish bodies of hard consistence, like dried mortar, and of a whitish color; both of the cases occurred in old women. Nothing is
said as to the size of these bodies, and nothing as to whether the glands were otherwise normal, or whether the concretions lay in tumors. Pre viously Gross says that such concretions are formed either in the substance of the gland or in the lactiferous ducts, seldom reaching the size of a pea, and are found in connection with fibrous and other tumors. Gross men tions a case, reported by Berar, in which the walls of a mammary cyst were completely covered in by a bony scale.
Velpeau doubts, from his literary researches, the credibility of this very imperfectly recorded case, which perhaps he himself had not seen; yet he (Velpeau) saw and described such a case. Velpeau saw several cases in old women, in which the breast was furrowed by chalky, hard plate parti tion walls, needles, which lay in the otherwise healthy glands. Anatomi cal examinations were not made in any of these cases, though Velpeau derived the impression that the calcareous masses lay partly in the con nective tissue and partly in the lactiferous ducts. Earlier observations of this kind will not bear serious criticism. It may be interesting to know that Morgagni claims to have known a widow, who had in her breast eral stones, which when she walked or gently shook herself, struck against one another, sounding like a small bell.
In themselves small concretions in the breast do not demand removal. Whether they arise from small caseous foci (yellow tubercles), or from so called " butter-cysts," by gradual absorption of the fluid elements, or from cretefaction of the connective tissue, is unknown. I have seen, in a man, an encapsulated, crumbling, chalky concretion in the mamma, such as is described by Gross; it gave the impression that the contents of the capsule were atheromatous and had become calcified; unfortunately the capsule was not thoroughly examined.