—The treatment of mastodynia should include constitutional, local, and moral measures, but of these the local are the least important. The excision of painful nodules is often disappointing, the remaining scars becoming even more sensitive than the original lesions. Women who under these circumstances have insisted upon the removal of an entire breast have still suffered from intercostal neuralgia or other remaining painful conditions, so that their ultimate condition has not been much improved. Each case should be studied upon its merits, and while one may be benefited by some pelvic operation, or another by Turkish baths and improvement of elimination, others are best let alone, or given a minimum of drugs with a maximum of general and sexual hygiene.
TUBERCULOSIS OF THE BREAST.
I cannot agree with writers like Fowler, who claim that tuberculosis of the mammary gland is extremely rare. I think it not infrequent. In the breast may be noted the presence of lesions, either separate or coalescing, and gummas as such, or breaking down into caseous masses or into cold abscesses. In connection with the local lesions there may be more or less involvement, even to ulceration, of the overlying skin, with the formation of lupoid ulcers, while the axillary lymphatics will be nearly always involved. In some instances the disease may have gone on to suppuration and burrowing of pus, with its discharge, and the existence of tuberculous sinuses; or in others may be seen results of a secondary infection of the remains of multiple mammary abscess. The condition is most often met with in the young and fair, but may be seen in elderly women. Around the distinctly tuberculous lesions there may be considerable tissue sclerosis. The actual proportion of cases is about one of this condition to fifty of cancer. Lesions are more frequent in the outer quadrant of the breast than the inner, and they occasionally produce retraction of the nipple or adhesion of the skin, above described, before its distinct involvement.
In any of these circumstances secondary purulent infection may occur, and an acute phlegmonous process may seriously complicate the previous chronic condition.
Treatment.
—There is but one satisfactory method of dealing with tuberculous disease of the breast—i. e., its extirpation. The entire breast, or so much of it as may be distinctly involved, should be extirpated as though it were cancerous, while the axilla should be opened and its contents cleared out, if it appear in the slightest degree involved. Moreover, every other tuberculous lesion in the neighborhood should be eradicated, either with the knife, the scissors, or the sharp spoon. After such radical treatment results are usually satisfactory.
ACTINOMYCOSIS; SYPHILIS OF THE BREAST.
Actinomycosis is not common in this location; nevertheless tissue conditions are such that it would furnish accessible and diagnosticable features which would be distinctive, at least until some secondary infection had occurred.
Syphilis appears in this location in many of its protean manifestations. Chancres about the nipples and on the surface of the breast are not uncommon, the disease being often conveyed from syphilitic infants through cracked nipples, while many other methods of contamination have been reported. Near the nipple the chancre may not have those characteristics which usually distinguish it upon the genitals, but may appear rather as an indurated, intractable ulcer, with firm base, accompanied by distinct involvement of the axillary and supraclavicular nodes, and unless early recognized and promptly treated as such will so endure until the occurrence of the first significant secondary eruption, whose appearance should dispel doubt and lead to radical treatment.
There is difficulty, sometimes, in distinguishing between tuberculous and syphilitic skin lesions upon the breast, especially near the nipple. When other methods fail the therapeutic test will nearly always clear up the difficulty. All truly syphilitic lesions here, as well as elsewhere, yield promptly to well-directed treatment.