238 S.A. MEDICAL JOURNAL 31 March 1962 TABLE m. MORE ADEQUATE SURVEYS FOR DEAF'!'o'ESS IN ­ 'Cb) 1'he need to promote, by trammg, the maximwn CEREBRAL PAlSY use of residual hearing and reliance upon it; No. Diagnosed condition No. % 'Cc) The need for expert assessment and periodic re­ deaf deaf Authors Date tested or type ofschool assessment during the progress of remedial training of the 26 62 Asher" 1952 42 Athetosis handicapped child's abilities, temperament, and general Crabtree and Gerrard' 1950 20 Following kernicterus 16 80 and mental growth; and 9 Fisch •• 1955 89 Special school 30 34 'Cd) The need for continuous study of a child's social Porter!· 1957 388 Special schools 271 70 development and the motivation towards learning which Fischll.. 1957 427 Cerebral palsy 107 25 Mowatl! 1961 70 Cerebral palsy in Dun- it offers him.' dee area 14 25 SUMMARY Fisch and BacklS 1961 76 19* 20 Early surveys of hearing defects in children afflicted with cerebral palsy underestimated the true incidence of deaf­ Total 1,112 483 45 ness. This can only be assessed after complete testing by "These 19 children had significant hearing loss. adeciuate methods. to stress the need for special arrangements to test the A plea is made that all children suffering from cerebral hearing in all cerebral palsy children. palsy should have an adequalte hearing test, and that The provision of special testing facilities appears at first facilities be provided for dealing. with those who are hard to be an expensive undertaking, particularly if testing has of hearing. to be done under ideal conditions in a sound-proof room. My thanks are due 10 Miss P. Mal<ks, of the University of However, Ewing" stated that 'sound-proof' rooms are not the Wilwatersrand Speech and Hearing Clinic, for performing needed for the administration of screening tests. The cost the screening tests on children at the Forest Town School, of screening, therefore, would be that of ·the pure-tone referred to in this article; also to Mrs. R. Jacobs, Miss R. Kaplan and Mrs. J. Stott, speech therapists at the school, who audiometer and the ,time taken. assisted in the compilation of material for this report. It is interesting to know that various authors (Ewing I wish to thank Dc. J. R. Lynch, Principal of the Forest and Mowat) pointed out that the incidence of deafness is Town School for Cerebral Palsied Children, for his kind unrelated to the child's intelligence, though Mowat found cooperation and permission to publish this article. that the greater the severity of the neurologioal lesion in REFERENCES cerebral palsy, the higher the incidence of deafness. 1. Connolly, G. (1959): 'The Education of Deaf Children, Suffering from Cerebral Palsy', M.Ed. thesis, Department of Education of the Deaf. University of Manchester. Educational Research'vo!. I. p. 76. EDUCATION 2. Asher, P. and Schonell, F. E. (1950): Arch. Dis. Childh., 25, 360. 3. Woods, G. E. (1957): Cerebral Palsy in Childhood. Bristol: Wright. Once it has been esl:a!blished tJhat a hearing loss exists, 4. Barclay, J. (1956): N.Z. Med. J., 55, 199. special education methods may be provided to compensate 5. MacGregor, M., Pirrie, D. and Shaddick, C. W. (1957): Med. oUr, 98, 367. for the defect. 6. Henderson, J. L. (1961): Cerebral Palsy in Childhood and Adolescenu, 14 Edinburgh & London: Livingstone. Ewing stated that if comprehensive provision for 7. Crabtree, W. and Gerrard. J. (1950): J. Laryng., 64, 482. children with cerebral palsy and hearing deficiencies is to 8. Asher, P. (1952): Arch. Dis. Childh., 27, 475. 9. Fisch, L. (1955): Lancet, 2, 370. be planned, the following will be found: 10. Porter, van C. (1957): Amer. Ann. Deaf, 102, 359. 11. Fisch. L. (1957): Speech, 21. 43. '(a) The need for special physical training and often 12. Mowat. J. in Henderson, J. L. ed. (1961): Op. cit.- of special physical conditions with regard to building and 13. Fisch. L. and Back, D. (1961): Cerebral Palsy Bull., 3. No. 2. - 14. Ewing, A. W. G. in lllingworth, R. S. ed. (1958): Recent AdvtVIU$ furniture; in Cerebral Palsy. London: Churchill. LACTIFEROUS DUCT FISTULA C. J. MIENY, M.B., CH.B. (FRET.), F.C.S.S.A., Department of Surgery, University of the Witwatersrand and Johannesburg General Hospital The true nature of lactiferous ~uct fistulae was described 1. Stasis of secretions within a lactiferous dyct. for the first time in 1951 by Zuska, Crile and Ayresl when 2. Dilatation and infection in the region of the ampulla. they reported 5 cases in the American literature. They 3. Ulceration of the ductal epithelium with extension of offered an explanation of the pathology of these chronic the inflammation into the breast tissue. breast fistulae and at the same time suggested a rational 4. The formation of a subareolar breast abscess. form of treatment for the condition. 5. Rupture of the abscess through the skin with the for­ Before publication of their paper there were numerous mation of an infected fistulous tract. references in the literature to the problem of the chronic Microscopically, they found the duct to be lined for the breast sinus. Deaver et al.,2 in 1917, described chronic most part by' hyperplastic squamous epithelium. Within sinuses following inadequate drainage of breast abscesses. the duct there are flat scales of keratin derived from the Dean Lewis3 described sinuses following chronic pyogenic lining epithelium. These keratin scales form the paste-like mastitis, and he, too, cited inadequate incision as an secretion which acts as the obstructing agent and which aetiological factor. Foote and Stewart4 called the condition can be expressed from the duct. A similar description of periductal mastitis. the pathology has been given by Patey and Thackray.5 PATBOGENESIS There have been several further reports of this condition Zuska, Crile and Ayresl postulated the following steps in since the classical description by Zuska, Crile and Ayres.1 the pathogenesis of this condition: Kilgore and Fleming6 reported 68 cases, drawing attention 31 Maart 1962 S.A. TYDSKRIF VIR GENEESKUNDE 239 TABLE I. DETAlLS OF PATIENTS WITH LACTIFEROUS DUCT 4. Frequently an inverted nipple on the side of the sinus. FISTULAE • Or, in the second group, in addition, multiple incisions Recurrences which have failed to heal, leaving a inus situated at the Case Age Marital status After Without margin of the areola or omewhere along the incisional incisions incisions car. E.H. 47 Unmarried 2 D.M. 36 Unmarried 2 In thi eries 3 of the patients were unmarried and in RB. 49 Unmarried 4 only 1 case wa the ab cess a 0 iated with lactation. All M.B. 33 Married. Lactation 3 the patients had inverted nipples confined to the side of A.M. 40 Married .. 3 the di ea e. On questioning, all the patients in i ted that S.S. 29 Married .. 2 "In all the patients the nipples were inverted on the side of the clisease the inverted nipples were normal before the condition only. occurred. Thus it would eem that inverted nipples in this to the common occurrence of inverted nipples in their serie might well be a result and not a cau e of the cases. In Atkins'1 series of 28 patients, 19 had inverted condition. nipples. According to these authors and others, inverted PATHOLOGY nipples, either congenital or acquired, are incriminated s The specimen from p<lltient M.B. was tudied in serial as a cause of this condition. sections by Mr. C. Toker, F.R.C.S., who reported the PRESENT SERIES following: Six patients with lactiferous duct fistulae have been en­ 'Histologic study of this resected specimen revealed countered over a period of 1 year at the Johannesburg alterations similar to those reported by Patey and Thack­ General Hospital (Table I). ray, and their views on the pathogenesis of the fistula appear to be applicable in this instance. A plug of keratin These cases can be divided into 2 clinical groups: was found to be occluding the ampullary area of the duct. 1. A group of patients who had subcutaneous abscesses The channel displayed marked dilatation, its greatest at the margin of the areola, which discharged spontane­ dimension being attained shortly below the ampulla. As ously with apparent resolution, only to recur again and the duct was followed more deeply into the breast sub­ again. stance the dilatation diminished, although some tortuosity 2. A group in which the patients underwent a series of was evident. Ultimately the epithelial lining disintegrated operations for breast abscesses, but the condition recurred completely and the ductal wall was replaced by a fistulous relentlessly. track whi.:h could be followed to the surface. This track The clinical findings were as follows (Fig. 1): was lined by inflammatory granulation tissue with con­ 1. A small sinus at the margin of the areola. siderable surrcunding fibrosis. 2. A band of dilated duct between the sinus and nipple. 'The histologic features were strongly suggestive of 3. A pasty secretion from the nipple. obstruction at the amimllary level, for it was here that the dilatation was maximal. The mass of keratin filling the ampul­ la was clearly dis­ cernible, and it was ,though.t justi­ fiable to regaad this as the occlu­ ding agent, for no other organic obstructing lesion was detectable along the entire course of the af­ fected channel: TREATMENT A rational fonn of treatment of this condition should thus be eXCISIon of the whole duct and fistula, and not simply incision of the abscess. Fig. 1. Patient A. M. ote sinus at the margin of the areola and Fig.