Paget’s disease of the nipple implies an eczematous condition, first described by Paget as a precursor of many cancers. It is a more or less chronic affection, involves the nipple and the areola, is quite intractable to treatment, gives more or less discomfort, and is to be dreaded when noted. It seems to sustain about the same relation to later cancerous involvement as does leukoplakia in the mouth and on the tongue.
There is no reason why any person may not have an attack of eczema about the nipple, but cases in which the condition is persistent and obstinate, and especially in which the underlying tissues gradually become infiltrated or indurated, should be viewed with suspicion, and should be treated by eradication of the area involved, even though this may require extirpation of the nipple or of the entire breast. When the condition is developed no ordinary treatment will suffice, although a fair trial might be given to the cathode rays.
MASTITIS.
A true inflammation of the mammary gland may occur at one of three periods: (1) At birth, when the tiny breasts of the newborn infant secrete a milk-like fluid, become more or less congested and tender, and when they are unintelligently treated by massage or interference of any kind; (2) at puberty, when a perfectly natural turgescence and congestion occur, which, however, rarely proceed to suppuration unless infected or unless violence or some indiscreet treatment have been received; (3) during pregnancy and lactation, this being the time when mastitis is most common.
Considering that the nipple affords a number of open paths, from an area which it is difficult to keep clean, extending into the depths of inflammable tissue, it is strange that infection through the milk ducts does not occur in most cases. Such a path of infection affords the explanation for at least a large proportion of mammary abscesses. Again the presence of excoriations, abrasions of any kind, and especially of deep fissures which are not easily cleansed, will account for infection through the lymphatics. In these two ways nearly all cases of mastitis and of mammary abscess are to be explained, and both these accidents are likely to occur during pregnancy and lactation.
The consequence of such infection is mastitis, which begins with painful induration and local indications of inflammation, but which may under suitable treatment undergo resolution. This failing, the infectious process proceeds to suppuration, and the consequence is a superficial, deep, or retromammary abscess, all but the last named often in multiple form. The lobular construction of the breast permits the independent occurrence of distinctive suppuration, occurring synchronously at several different points, and hence it may be that a breast is riddled with abscesses, which form successively or almost simultaneously.
There is a superficial form, which occurs usually near the nipple, and in which the deeper structure of the breast is scarcely involved. This comes usually through infection of some surface lesion. Simple incision is usually sufficient, and the local lesion is thus quickly terminated. Deep or intramammary abscess, single or multiple, is always painful, sometimes distressing and occasionally an extremely serious condition. Occurring in a breast already well developed and fatty, abscesses may form at such depth as to be recognized with difficulty. The surgeon infers their existence rather than discovers it. This is unfortunate, for the longer the delay the greater the local disturbance, with a tendency to burrowing, and the worse are the consequences for the patient. It is, therefore, far safer to early note the minor signs of deep suppuration and to freely incise, than it is to wait for pus to come toward the surface and give its ordinary surface indications. The amount of induration, sometimes dense and brawny, which such conditions will produce within the breast, the size which the latter may assume, and the consequent suffering to the patient from neglected conditions of this kind, need to be seen to be fully appreciated.
Retromammary abscess may be the result of conditions not primary to the breast itself. Thus the writer has seen spontaneous perforation of the thoracic wall in a case of empyema, with escape of pus into the loose cellular tissue behind the breast, and the consequent protrusion forward of the latter until it presented as an enormous tumor. Treatment in such cases would mean not alone evacuation of the retromammary collection, but emptying the pleural cavity of its accumulated fluid.
An infected breast will produce not only the ordinary local indications, but will be characterized by extreme tenderness, with enlargement of the lymph nodes in the axilla and later abscess formation in this location. In proportion to the amount of pus thus imprisoned, and the virulence of the infecting organisms, constitutional symptoms may be mild or extreme.
Nowhere is there greater need for release of an imprisoned amount of pus than under these circumstances, although the incisions necessary for the purpose may be sometimes multiple and deep. Every incision made for evacuation of a mammary abscess should be placed radially—i. e., in a line radiating from the nipple—in order that lobules may be incised along their course, and that neither they nor vessels be cut across transversely. There is also need for complete drainage, and several tubes may be used for this purpose, being passed completely across or beneath the breast.