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An unusual case of breast abscess
AN UNUSUAL
CASE OF
BREAST ABSCESS* GAYLORD S. BATES, M.D. DETROIT,
B
abscess is a surgica1 condition reIativeIy rare occurrence. By the greater percentage of cases women during Iactation or, Iess pregnancy. FIeckl coIIected 430
REAST
of far occur in often, in
cases from the Iiterature and found onIy 5.8 per cent occurred during pregnancy.
BiIIroth, Nunn and Bryant2 among them coIIected 230 cases of abscess of the breast, of which onIy 34, or 14.7 per cent were unconnected with pregnancy or Iactation. The sources of infection in this smaIIer group are as interesting as they are varied. VeIpeau3 described a case which he saw in 1844: . . vast abscess of the right breast, consequent on puruIent formation in the axiIIa which, in turn, was consequent on chiIIbIains; [and] an axiIIary abscess, consequent on erysipeIas produced by a bIister on the Ieft arm; incision with free drainage; abscess of the Ieft breast; incision; poultices; cure in five weeks. [VeIpeau’s experience with uncommon forms of breast abscess was apparentIy rich, for] I have seen an abscess form beneath the mamma, consequent on the inflammation and suppuration of the perichondrium of a broken sternocosta1 cartiIage. In many other patients the abscess has been caused by some Iong standing change in the subjacent ribs. In 1834, I met with an enormous submammary abscess communicating with the bronchi which folIowed an attack of pneumonia of seemingIy miId character. In 1836, there was a woman in La Charite in whom the abscess originated in a tubercuIous mass under the sternum. At the same time a young gir1 had one which arose between the anterior border of the right Iung and the costal pIeura. PuImonary phthisis is a source of them which shouId not be forgotten, and of which I have witnessed many exampIes. I have aIso seen a great variety of submammary abscesses arising from various diseases of the chest in which instances, in short, they were IittIe more than depots from gravitation. * Submitted
MICH.
ShieId4 reports many cases of breast abscesses where the origin couId not be discovered, and speaks of the rarity of this condition in pyemia though cases are on record where such was the case, as after a recent operation or septic abortion. Deaver5 first caIIed attention to those rare instances where an abscess of the breast occurs independentIy of Iactation and in the absence of a history of trauma. These cases occur aImost without exception in patients whose nipples and areolae are congenitaIIy deformed. He quotes 2 histories of Duvergey where the phenomenon is attributed to maIformation of the nippIe which, being sunken, would easiIy become the receptacIe for dust, and retain the secretions of the skin in which the microorganisms are pIentifu1. Many cases have a direct and immediate reIation to trauma or wounding of the breast. FitzwiIIiams6*7 reports many such cases, beIieving that suppuration after definite trauma, such as a bIow, is due to the effusion of bIood, the formation of a hematoma, with subsequent suppuration due to the Iodgement of organisms in the cIot. In 2 instances there was no history of trauma. In I case, a pure cuIture of staphyIococcus was obtained from a breast abscess foIIowing a sore throat of influenza1 origin; again, in a woman who had been in poor genera1 condition for some months a breast abscess occurred foIIowing the appearance of severa abscesses about the mouth. Davis* observed I case which foIIowed the scaIding of the breast with coffee, a pure cuIture of streptococcus being obtained from the abscess. Breast abscess caused by B. typhosus foIIowing typhoid fever, is one of the rarest of compIications in that disease, yet by 1915 there had been 32 authentic cases
for pubIication September
359
5,
1930.
360
American Journal of Surgery
Bates-Breast
recorded. GerIach,9 Schiffmann,lo Snoke and Goforth,ll have each reported a case since that time; and Dyke12 has reported I case occurring in a typhoid carrier. OxIey13 witnessed a suppurating breast in which gonococci were found to be the exciting organism. This patient had a primary genitaI focus of three weeks’ duration. The manner in which the gonococcus became implanted in the breast is not stated. According to FitzwiIIiams,6 this is the onIy case of its kind to be found in the Iiterature. CASE
REPORT
CASE No. 46956, married, white, housewife, aged fifty-five, entered the surgical service of Drs. McLean, Barrett, and MacKenzie, May 5, 1930, compIaining of sweIIing of the right breast with pain, fever, and anorexia of three weeks’ duration. About three weeks before entry the patient noticed a sweIIing in the Ieft side of the neck which foIIowed immediateIy on scratching an “eczema” of the Ieft ear. Within a few days the sweIIing extended downward, mesiaIIy, and into the right breast which became enIarged, tender, and reddened. With this extension there was a high fever, IO~OF., with deIirium for nearIy twenty-four hours. The famiIy physician diagnosed erysipeIas. With pouIticing, 3 smaI1 patches of epitheIium sIoughed off just above and mesia1 to the nippIe, and for two weeks there was a sanguinopuruIent discharge from these sinuses. The fever diminished but the breast remained greatIy swoIIen, and was painfu1 to the Ieast motion. Except for anorexia there were no other symptoms. About five days before entry the upper part of the right breast enIarged rapidIy, and a tender sweIIing appeared over the right cIavicIe, and extended across the front of the neck to the Ieft side. The fever increased and the patient was brought to the hospita1. Examination on admission of the patient reveaIed an eIderIy, obese femaIe lying quietIy in bed, face ffushed, breathing rapidIy, eyes bright, mentaIIy cIear but obviousIy acuteIy iI1. The right breast, normaIIy Iarge and penduIous, was swoIIen to nearIy twice the size of the Ieft breast, the sweIIing extending upward into both sides of the neck, posteriorIy as far
Abscess as the upper borders of the trapezeii. Over this whoIe area the skin was reddened, tense and hot. In the region of the nippIe, were severa smaI1 uIcerations fiIIed with fibrin. SeveraI gIands were paIpabIe in the Ieft posterior triangIe of the neck. Temperature IOO.~‘F.; Respiration 26; PuIse IOO. BIood count: Hb 80 per cent; R. B. C. 3, 150,000; W. B. C. 7650; P. 82, L. 16, M. 2. The urine showed a sIight trace of aIbumin. In the operating room Iinear incisions were made in both infracIavicuIar regions from which Iarge amounts of oId bIood and pus escaped. AIso Iinear incisions were made in the right axiIIary Iine and right border of the breast from which Iarge amounts of pus were evacuated. Soft rubber drains were inserted and the wounds Ieft open. CuIture from the wound grew staphyIococcus aureus. The temperature fIuctuated between 99 and 103~~. The wounds drained copiousIy a sanguino-puruIent discharge. The patient became drowsy after operation and took ffuids onIy by hypodermocIysis. BIood cuIture on the sixth day gave no growth. Death occurred ten days after admission. Permission for autopsy couId not be obtained. According to Kaufman,14 in infectious mastitis, pyogenic organisms invade the breast (I) through the nippIe, (2) through the miIk ducts, (3) aIongside the miIk
ducts through the Iymph channeIs but in rare cases a mastitis may occur (4) by metastasis in a pyemic, usuaIIy puerpera process, or in typhoid fever, or even from the thorax (empyema, caries). This case beIongs in the last category as a Iymphogenous metastasis from a focus in the Ieft auricuIa, extending as an acute, diffuse inffammation of the skin and subcutaneous tissues, a true phIegmon. In situations where the skin is thin a phIegmon may simuIate erysipeIas in appearance, a fact which Ied to confusion and deIay in this instance. The mammary gIands are of ectoderma1 origin and are regarded by most authorities as modified sweat gIands;15 this, together with the knowIedge that the superficia1 Iymphatic vesseIs of the anterior part of the neck freeIy anastamose with those beIow
NEW
SERIES
VOL. XI, No. 2
CIeveIand--Fusion
of Knee-Joint
the cIavicIe, and that the superficia1 vesseIs on both sides of the anterior thorax freeIy anastamose across the front of the ster-
num,16 serves extension of described.
American Journal of Surgery
361
to expIain the manner of the infection in the case
REFERENCES I. FLECK,
2. 3.
4. 5.
6. 7.
8.
G. MittheiIungen nus der Giittingen Frauenkbnik. Arch. “_ f. Gvntik.._-I__ 64: 872, 19~1. BILLROTH. Krankheiten d. Brustdriisen. Stuttgart, 1880, p. 1*. VELPEAL.. A Treatise on the Diseases of the Breast and Mammary Region. 1856. Tr. from the French by MitcheII Henry. SHIELD. Diseases of the Breast. N. Y., MacmiIIan, 1898. DEAVER, J. B., and MCFARLAND, J. The Breast: Its Anomalies, Diseases, and Their Treatment. PhiIa., BIakiston, 1916. FITZWILLIAMS, D. C. L. On the Breast. St. Louis, Moshy, 1925. FITZWILLIAMS, D. C. L.. Chronic and rare forms of suppuration in the breast. Practitioner, II I : 173, 1923. DAVIS, E. P. Streptococcus infection of the breast in pregnancy. Am. J. Obst. c @net., 59: 1043, Igog.
9. GERLACH, W. Ein FaII von Spltabszess nach Mastitis typhosa. Miinchen. med. Wchnscbr., 74: 1324. 5, 1927. IO. SCHIFFMANN, J. Mastitis typhosa suppurativa biIateraIis. Deutsche med. Wcbnschr., 53: 1634, 1927. II. SKOKE, P. O., and GOPORTH, J. L.. Typhoid abscess of breast, case simulating tumor; pathologic report. Am. J. M. SC., 171: 555, 1926. 12. DYKE, S. C. Abscess of breast occurring in a typhoid carrier. Lancet, 2: 331, 1913. 13. OXLEY, W. H. F. Case of gonorrhea1 mastitis. Brit. M. J., 2: 744, rgzo. 14. KAUFMANN. Pathology. Tr. by S. Reimann. PhiIa., BIakiston, 1929. ‘5. AREY. DeveIopmentaI Anatomy. PhiIa., Saunders, 1924. 16. GRAY. Anatomy of the Human Body. Ed. 21, Phila. Lea Bi Febiger, 1924.
FUSION OF KNEE#JOINT IN A CASE OF CHARCOT’S MATHER
CLEVELAND, NEW
A
A
L
FIFTY-ONE
for treatment pedic
Dispensary
year oId negro applied at the New York Orthoin November,
Ig28.
a swoIIen Ieft knee and Iimited motion, but a IittIe IateraI instabiIity. He had a positive Romberg’s sign. Voluntary sensation in the Ieg decreased. The pupiis were irreguIar and sIuggish. The roentgenograph showed Ioss of substance of the interna tabIe of the tibia1 head, with condensation and disorganization of the joint, and considerabIe effusion and detritus throughout the joint. The Wassermann reaction was 4 pIus. Diagnosis: Charcot’s disease of knee-joint. The patient was admitted to Sea View HospitaI, November 1g, 1928. Operation: Fusion of knee-joint, Hibbs’ technique. SpinaI He had
* Submitted
DISEASE* M.D.
YORK
anesthesia. SpinaI ffuid showed 2 pIus Wassermann reaction; joint ffuid showed 4 plus Wassermann reaction. The tissue was reported as showing chronic hyperpIastic arthritis, probabIy of syphiIitic origin. The Ieg was immobiIized by a pIaster-of-Paris spica for two months, and then a Iong Ieg circuIar plaster-of-Paris spIint for four months. Fusion of the knee-joint was soIid at six months, and the patient went home ten months after the operation. He now waIks weI1, the instabiIity of the knee is gone, and he is pIeased with the resuIt. His Iast Wassermann test was stiI1 4 PIUS, in spite of a good dea1 of antiIuetic treatment. This is a very fortunate outcome, which cannot be expected in every case of Charcot’s disease of the knee-joint.
for pubIication
June 4, 1930.
CASE OF
BREAST ABSCESS* GAYLORD S. BATES, M.D. DETROIT,
B
abscess is a surgica1 condition reIativeIy rare occurrence. By the greater percentage of cases women during Iactation or, Iess pregnancy. FIeckl coIIected 430
REAST
of far occur in often, in
cases from the Iiterature and found onIy 5.8 per cent occurred during pregnancy.
BiIIroth, Nunn and Bryant2 among them coIIected 230 cases of abscess of the breast, of which onIy 34, or 14.7 per cent were unconnected with pregnancy or Iactation. The sources of infection in this smaIIer group are as interesting as they are varied. VeIpeau3 described a case which he saw in 1844: . . vast abscess of the right breast, consequent on puruIent formation in the axiIIa which, in turn, was consequent on chiIIbIains; [and] an axiIIary abscess, consequent on erysipeIas produced by a bIister on the Ieft arm; incision with free drainage; abscess of the Ieft breast; incision; poultices; cure in five weeks. [VeIpeau’s experience with uncommon forms of breast abscess was apparentIy rich, for] I have seen an abscess form beneath the mamma, consequent on the inflammation and suppuration of the perichondrium of a broken sternocosta1 cartiIage. In many other patients the abscess has been caused by some Iong standing change in the subjacent ribs. In 1834, I met with an enormous submammary abscess communicating with the bronchi which folIowed an attack of pneumonia of seemingIy miId character. In 1836, there was a woman in La Charite in whom the abscess originated in a tubercuIous mass under the sternum. At the same time a young gir1 had one which arose between the anterior border of the right Iung and the costal pIeura. PuImonary phthisis is a source of them which shouId not be forgotten, and of which I have witnessed many exampIes. I have aIso seen a great variety of submammary abscesses arising from various diseases of the chest in which instances, in short, they were IittIe more than depots from gravitation. * Submitted
MICH.
ShieId4 reports many cases of breast abscesses where the origin couId not be discovered, and speaks of the rarity of this condition in pyemia though cases are on record where such was the case, as after a recent operation or septic abortion. Deaver5 first caIIed attention to those rare instances where an abscess of the breast occurs independentIy of Iactation and in the absence of a history of trauma. These cases occur aImost without exception in patients whose nipples and areolae are congenitaIIy deformed. He quotes 2 histories of Duvergey where the phenomenon is attributed to maIformation of the nippIe which, being sunken, would easiIy become the receptacIe for dust, and retain the secretions of the skin in which the microorganisms are pIentifu1. Many cases have a direct and immediate reIation to trauma or wounding of the breast. FitzwiIIiams6*7 reports many such cases, beIieving that suppuration after definite trauma, such as a bIow, is due to the effusion of bIood, the formation of a hematoma, with subsequent suppuration due to the Iodgement of organisms in the cIot. In 2 instances there was no history of trauma. In I case, a pure cuIture of staphyIococcus was obtained from a breast abscess foIIowing a sore throat of influenza1 origin; again, in a woman who had been in poor genera1 condition for some months a breast abscess occurred foIIowing the appearance of severa abscesses about the mouth. Davis* observed I case which foIIowed the scaIding of the breast with coffee, a pure cuIture of streptococcus being obtained from the abscess. Breast abscess caused by B. typhosus foIIowing typhoid fever, is one of the rarest of compIications in that disease, yet by 1915 there had been 32 authentic cases
for pubIication September
359
5,
1930.
360
American Journal of Surgery
Bates-Breast
recorded. GerIach,9 Schiffmann,lo Snoke and Goforth,ll have each reported a case since that time; and Dyke12 has reported I case occurring in a typhoid carrier. OxIey13 witnessed a suppurating breast in which gonococci were found to be the exciting organism. This patient had a primary genitaI focus of three weeks’ duration. The manner in which the gonococcus became implanted in the breast is not stated. According to FitzwiIIiams,6 this is the onIy case of its kind to be found in the Iiterature. CASE
REPORT
CASE No. 46956, married, white, housewife, aged fifty-five, entered the surgical service of Drs. McLean, Barrett, and MacKenzie, May 5, 1930, compIaining of sweIIing of the right breast with pain, fever, and anorexia of three weeks’ duration. About three weeks before entry the patient noticed a sweIIing in the Ieft side of the neck which foIIowed immediateIy on scratching an “eczema” of the Ieft ear. Within a few days the sweIIing extended downward, mesiaIIy, and into the right breast which became enIarged, tender, and reddened. With this extension there was a high fever, IO~OF., with deIirium for nearIy twenty-four hours. The famiIy physician diagnosed erysipeIas. With pouIticing, 3 smaI1 patches of epitheIium sIoughed off just above and mesia1 to the nippIe, and for two weeks there was a sanguinopuruIent discharge from these sinuses. The fever diminished but the breast remained greatIy swoIIen, and was painfu1 to the Ieast motion. Except for anorexia there were no other symptoms. About five days before entry the upper part of the right breast enIarged rapidIy, and a tender sweIIing appeared over the right cIavicIe, and extended across the front of the neck to the Ieft side. The fever increased and the patient was brought to the hospita1. Examination on admission of the patient reveaIed an eIderIy, obese femaIe lying quietIy in bed, face ffushed, breathing rapidIy, eyes bright, mentaIIy cIear but obviousIy acuteIy iI1. The right breast, normaIIy Iarge and penduIous, was swoIIen to nearIy twice the size of the Ieft breast, the sweIIing extending upward into both sides of the neck, posteriorIy as far
Abscess as the upper borders of the trapezeii. Over this whoIe area the skin was reddened, tense and hot. In the region of the nippIe, were severa smaI1 uIcerations fiIIed with fibrin. SeveraI gIands were paIpabIe in the Ieft posterior triangIe of the neck. Temperature IOO.~‘F.; Respiration 26; PuIse IOO. BIood count: Hb 80 per cent; R. B. C. 3, 150,000; W. B. C. 7650; P. 82, L. 16, M. 2. The urine showed a sIight trace of aIbumin. In the operating room Iinear incisions were made in both infracIavicuIar regions from which Iarge amounts of oId bIood and pus escaped. AIso Iinear incisions were made in the right axiIIary Iine and right border of the breast from which Iarge amounts of pus were evacuated. Soft rubber drains were inserted and the wounds Ieft open. CuIture from the wound grew staphyIococcus aureus. The temperature fIuctuated between 99 and 103~~. The wounds drained copiousIy a sanguino-puruIent discharge. The patient became drowsy after operation and took ffuids onIy by hypodermocIysis. BIood cuIture on the sixth day gave no growth. Death occurred ten days after admission. Permission for autopsy couId not be obtained. According to Kaufman,14 in infectious mastitis, pyogenic organisms invade the breast (I) through the nippIe, (2) through the miIk ducts, (3) aIongside the miIk
ducts through the Iymph channeIs but in rare cases a mastitis may occur (4) by metastasis in a pyemic, usuaIIy puerpera process, or in typhoid fever, or even from the thorax (empyema, caries). This case beIongs in the last category as a Iymphogenous metastasis from a focus in the Ieft auricuIa, extending as an acute, diffuse inffammation of the skin and subcutaneous tissues, a true phIegmon. In situations where the skin is thin a phIegmon may simuIate erysipeIas in appearance, a fact which Ied to confusion and deIay in this instance. The mammary gIands are of ectoderma1 origin and are regarded by most authorities as modified sweat gIands;15 this, together with the knowIedge that the superficia1 Iymphatic vesseIs of the anterior part of the neck freeIy anastamose with those beIow
NEW
SERIES
VOL. XI, No. 2
CIeveIand--Fusion
of Knee-Joint
the cIavicIe, and that the superficia1 vesseIs on both sides of the anterior thorax freeIy anastamose across the front of the ster-
num,16 serves extension of described.
American Journal of Surgery
361
to expIain the manner of the infection in the case
REFERENCES I. FLECK,
2. 3.
4. 5.
6. 7.
8.
G. MittheiIungen nus der Giittingen Frauenkbnik. Arch. “_ f. Gvntik.._-I__ 64: 872, 19~1. BILLROTH. Krankheiten d. Brustdriisen. Stuttgart, 1880, p. 1*. VELPEAL.. A Treatise on the Diseases of the Breast and Mammary Region. 1856. Tr. from the French by MitcheII Henry. SHIELD. Diseases of the Breast. N. Y., MacmiIIan, 1898. DEAVER, J. B., and MCFARLAND, J. The Breast: Its Anomalies, Diseases, and Their Treatment. PhiIa., BIakiston, 1916. FITZWILLIAMS, D. C. L. On the Breast. St. Louis, Moshy, 1925. FITZWILLIAMS, D. C. L.. Chronic and rare forms of suppuration in the breast. Practitioner, II I : 173, 1923. DAVIS, E. P. Streptococcus infection of the breast in pregnancy. Am. J. Obst. c @net., 59: 1043, Igog.
9. GERLACH, W. Ein FaII von Spltabszess nach Mastitis typhosa. Miinchen. med. Wchnscbr., 74: 1324. 5, 1927. IO. SCHIFFMANN, J. Mastitis typhosa suppurativa biIateraIis. Deutsche med. Wcbnschr., 53: 1634, 1927. II. SKOKE, P. O., and GOPORTH, J. L.. Typhoid abscess of breast, case simulating tumor; pathologic report. Am. J. M. SC., 171: 555, 1926. 12. DYKE, S. C. Abscess of breast occurring in a typhoid carrier. Lancet, 2: 331, 1913. 13. OXLEY, W. H. F. Case of gonorrhea1 mastitis. Brit. M. J., 2: 744, rgzo. 14. KAUFMANN. Pathology. Tr. by S. Reimann. PhiIa., BIakiston, 1929. ‘5. AREY. DeveIopmentaI Anatomy. PhiIa., Saunders, 1924. 16. GRAY. Anatomy of the Human Body. Ed. 21, Phila. Lea Bi Febiger, 1924.
FUSION OF KNEE#JOINT IN A CASE OF CHARCOT’S MATHER
CLEVELAND, NEW
A
A
L
FIFTY-ONE
for treatment pedic
Dispensary
year oId negro applied at the New York Orthoin November,
Ig28.
a swoIIen Ieft knee and Iimited motion, but a IittIe IateraI instabiIity. He had a positive Romberg’s sign. Voluntary sensation in the Ieg decreased. The pupiis were irreguIar and sIuggish. The roentgenograph showed Ioss of substance of the interna tabIe of the tibia1 head, with condensation and disorganization of the joint, and considerabIe effusion and detritus throughout the joint. The Wassermann reaction was 4 pIus. Diagnosis: Charcot’s disease of knee-joint. The patient was admitted to Sea View HospitaI, November 1g, 1928. Operation: Fusion of knee-joint, Hibbs’ technique. SpinaI He had
* Submitted
DISEASE* M.D.
YORK
anesthesia. SpinaI ffuid showed 2 pIus Wassermann reaction; joint ffuid showed 4 plus Wassermann reaction. The tissue was reported as showing chronic hyperpIastic arthritis, probabIy of syphiIitic origin. The Ieg was immobiIized by a pIaster-of-Paris spica for two months, and then a Iong Ieg circuIar plaster-of-Paris spIint for four months. Fusion of the knee-joint was soIid at six months, and the patient went home ten months after the operation. He now waIks weI1, the instabiIity of the knee is gone, and he is pIeased with the resuIt. His Iast Wassermann test was stiI1 4 PIUS, in spite of a good dea1 of antiIuetic treatment. This is a very fortunate outcome, which cannot be expected in every case of Charcot’s disease of the knee-joint.
for pubIication
June 4, 1930.