Chronic Mastitis.
—Chronic mastitis may be the termination of a partially resolved acute process, or of injury, or of apparently unknown causes, being in these instances of apparently spontaneous origin. Pathologically it comprises induration, with more or less infiltration of the interacinous and interlobular tissue, and with some infiltration of the other structures of the breast, by which fixation, retraction of the nipple, or condensation of the surrounding structures and adhesion of the overlying skin are produced. The result may be to produce either an enlargement or diminution in size of the breast. One or both glands may be involved. It is a disease usually of late adult life.
Breasts thus affected are often tender and painful, especially during menstruation, and upon palpation are found to be irregular in shape, more or less nodulated, extremely firm in some cases and places, and perhaps so infiltrated as to strongly simulate cancer. The changes which are thus produced are slow, and it is important to note that the lymphatics are usually not enlarged, and that after attaining a certain degree the diseased condition becomes stationary. The general health usually does not suffer beyond a certain point; at least even in the more chronic cases there is no characteristic cachexia. While the condition is more frequent in women who have nursed it may be met in those who have never borne children nor have been married.
Suitable examination of all these cases can only be made with the upper portion of the patient stripped, the body in the horizontal position, and both breasts compared and examined, first with the flat hand in order that differences of shape, size, mobility, and fixation may be determined. Subsequently the patient should be raised to the sitting position, the surgeon standing behind to examine each breast with one hand and simultaneously, in order that differences may be more accurately noted. Any tumor present will be more easily discovered with the flat hand than with the finger-tip, while chronic induration will not give the sensation given by neoplasms. The axillæ should also be carefully examined, as well as the supraclavicular regions, for evidences of lymphatic involvement. When the entire breast is involved diagnosis is less difficult than when one or more lobules alone are concerned. These constitute the painful nodular conditions to which so many names have been given by different writers.
Significant features in their differentiation from cancer are the disproportionate pain and tenderness, their diffuse leathery hardness, and the fact that both breasts are usually similarly involved, though perhaps not to the same extent. Cancer is, on the other hand, somewhat dense and confined to one breast, and affords a sensation of infiltration of the surrounding tissues, with the peculiar “saddle-skin” retraction or adhesion of the overhang skin and nipple. Moreover, the growth is more rapid and localized, and the lymphatics are involved in nearly every instance. Some of these cases are so obscure that diagnosis previous to operation is impossible, while innocent lesions may gradually merge into malignant, and no one can say when the transition begins or has begun.
Treatment.
—The milder forms of chronic mastitis gradually improve under the influence of local applications such as the ichthyol-mercurial ointment, to which menthol may be added for its soothing effect. Pendulous or painful breasts should be supported as much as possible. Otherwise these cases are best let alone—i. e., they should not be rubbed or massaged. There is usually a constitutional condition which is closely related, and in nearly every instance there is more or less failure of elimination. These features should be studied and treated as they are identified. Finally there are some intractable forms of innocently indurated breast which give so much trouble that it is best to remove them as though they were cancerous.
NEURALGIA OF THE BREAST; MASTODYNIA.
Many women suffer from annoying and painful affections of the breast for which no sufficient excuse is found, while others who have small fibrous nodules or innocent lobular tumors will suffer an amount of pain which is disproportionate, and in instances of either type we are prone to point to the neurotic or hysterical features of the case and to say that it must be, at least to a certain extent, neurotic. Inasmuch as these cases usually occur in young and otherwise neurotic women, often of the more impressionable type, it is generally proper to consider them as to some extent hysterical, while in others there are pelvic accompaniments which may perhaps account for neuralgic breasts, because of the well-known intimate relations between the pelvic organs and these glands. In some cases, again, are found actual small tumors, single or multiple, but of innocent character. In other cases there are hypersensitive areas of entire breasts, to a degree where the patient cannot stand the slightest handling. These cases are hyperesthetic, even if not hysterical, and some are unsatisfactory to treat. The pains are more or less periodical, and often radiate down the arm or the side of the thorax; this may be explained through the intercostohumeral and other nerve connections.