Ehrlick and I (Arch. f. El. Chir., Bd. XX., p. 418) have shown the pres ence of enormous masses of coccus-vegetations in a hypertrophic mamma, which was attacked by erysipelas. I cite the short communication: " A. third case occurred in a young girl with enormously hypertrophied breasts. A reduction of their mass was attempted by compression with elastic bandages; this had some effect, but soon the breasts became painful, and from some excoriated points there was developed a phlegmonous erysipe las, which carried off the patient in a few days. In order to investigate the hypertrophic mamma?, at first without reference to the erysipelas,pieces of the breast were removed and preserved in Mailer's fluid. The large number of cocci contained in the diseased organs was an entirely accidental discovery. Many of the blood-vessels surrounding the enlarged acini were so densely filled with these balls of cocci, that it seemed as if a very large artificial gelatine-injection had been made. Here and there in the tissue cocci were found, but sparsely. The tissue surrounding the ves sels containing the cocci was entirely unchanged. Unfortunately none of the skin covering the mammw was preserved, so that nothing can be said as to whether it contained cocci or not in this case." At the time these investigations were made, Langhaus's work on the lymphatic vessels of the mamma was not known, or else it would have appeared probable to us then that these canals around the acini, in which the coccus-balls lay, were dilated lymphatics. It is plausible, however, from other researches, that there are occasions when a consid erable time elapses before a coccus-invasion causes inflammation and sup puration. It is even maintained by many that this follows only in an indirect way, that the contact of the coccus With the tissue acts much more directly and deleteriously upon it, that it immediately causes death, necrosis, and the suppuration is the result of the necrosis. I remember very clearly that the mammary tissue of a patient, which was studded with adeno-fibromata, was remarkably red, with here and there, perhaps, a, yellow spot, as if of purulent infiltration, but at no place was there an abscess. Although there was no puerperal mastitis in this case, and al though, at all events, the lactiferous ducts had not determined the direction of the inflammation, yet in this case also, the immediate sur roundings of the lobules were the centre of the coccus vegetations, which, as in puerperal mastitis, would have caused abscesses with necrosis of the lobules.
Besides the typical form of " parenchymatous puerperal mastitis," which has been described, there remains the " puerperal paramastitis," a phleg mon which may develop partly upon the gland, partly behind it. The phlegmonous processes on the anterior surface of the gland arise usually around Montgomery's glands in the areola, and spread over the whole areola. Such subcutaneous cellular-tissue abscesses seldom arise in the peripheral portions of the mamma ; these processes seldom spread, but rapidly form small abscesses at their point of origin. This form of para mastitis occasionally developes outside of the puerperal state, sometimes as a result of a deep-seated erysipelas ambulans.
As regards the inflammation of the cellular tissue posterior to the mamma, it probably occurs only during the puerperium. In my experi ence these cases always result in abscess of the deep-seated portions of the gland. The pus breaks through the fascia-like connective tissue of the gland into the loose cellular tissue, which separates the gland from the pectoralis major muscle, and spreads out here in all directions to such an extent as to lift it from the thorax; it seeks an exit at the periphery of the gland or is let out here by an incision. Whether a " primary re tro-mastitis" ever occurs without a coincident parenchymatous mastitis, I cannot say. I have seen in men very large acute abscesses upon and
under the pectoralis major muscle, for which there was no known cause, and it is possible that the same thing may occur in women.
Whether a mastitis arising during a puerperal fever is of a metastatic nature (whether it is to be placed on a parallel with abscesses, as they sometimes occur in other organs and in the cellular tissue in pyEemia,) is hard to say. There seems to be no doubt, though, that a very extensive suppurating mastitis may lead to pytemia; it would not appear strange, reasoning from other observations, if slight cases of puerperal diseases of the genitals, which usually heal without difficulty, should, under the in fluence of a pymmia caused by mastitis, go on to marked suppuration; under these circumstances it would be difficult to decide which of the purulent foci found on section was the primarily infecting and which the infected. Hennig mentions a case of metastatic mastitis occurring in the course of typhus fever after a preceding parotitis.
SymptantR, Course and Proynosis.—The commencement of a mastitis first manifests itself by pain in the breast; this pain is at first limited to a certain part of the breast, is increased by movement of the affected part of the gland, by dependence of the gland and by the act of nursing. Palpation of the painful part, if the inflammation be not too deep-seated, reveals a hardness and a more or less sharply defined nodule, which en larges in the course of a few days. The affection frequently begins with a very high fever; often with a chill. With the formation of an abscess and the evacuation of the pus, the fever subsides completely if the pro cess terminates here. As in many cases, however, the inflammation passes from one lobule to another, the fever exacerbates and indicates here, as in other cases, whether the inflammatory process in the diseased organ has ceased or not.
The different forms of puerperal mastitis may be entirely dissipated by early and judicious treatment. More frequently, however, abscesses form, either upon or in the gland, according to the seat of the inflamma tion. Redness and circumscribed fluctuation soon appear in simple phlegmon of the mamma; in abscess posterior to the gland, a fluctuating tumor appears at some point in the circumference of the gland, usually below and to the outer side. In inflammation in the gland several ab scesses are usually formed, one near the other, in succession, which either empty into one another in the interior of the gland, thus forming sinu ous suppurating cavities, or they open through the skin at different points. As in other inflammations, large or small fragments of gland tissue may be thrown off. The spontaneous openings through the skin are usually very small, and are a long time in occurring; their course is therefore a very painful one. The prognosis as regards life is seldom of great mo ment; only in very weak, tuberculous women can an acute inflammatory process of a week's duration be considered dangerous, partly from the drain occasioned by the formation of pus, and partly through its exciting a fresh tuberculOus outbreak in the lungs. Rupture of a retro-mammary abscess into the pleural cavity is exceedingly rare. These cases often hang on for a long time, not only because of the formation of new abscesses, but because the old ones will not close; fistulae remain, the treatment of which will be spoken of later. Since two of the fifty-six cases of puerperal mastitis treated at my clinic died, it is proper .to state that one had thrombosis of both femoral veins when she was admitted, and the other died of an erysipelas ambulans contracted at the clinic. In neither case, therefore, was the mastitis the direct cause of death.