Debbie has a very challenging case, and I have no clue what to add. But
after reading her post,
I felt inspired to google "A horse of a different color".


< We all remember Dorothy getting by the blustering doorman at the entrance
to the Emerald City by the skin of her Ruby Slippers, and hailing a carriage
drawn by a horse whose color keeps changing. "What kind of a horse is that?
I've never seen a horse like that before!" she exclaims. To which the cabbie
replies, "No, and never will again, I fancy. There's only one of him, and
he's it. He's the Horse of a Different Color you've heard tell about." The
cabbie is referring to an expression used when you encounter something
significantly different from what is expected--you say that it's a *horse of
a different (or another) color*.

That the phrase *horse of a different color* has been around awhile is
evident by the fact that it was common enough in Shakespeare's time for him
to play on its meaning, as he does in *Twelfth Night.>*

Debbie wrote:


<Hi All,

I've been eager to post an update on the mom I've been helping all
weekend.
Thanks to all of you who replied on- and off-list with all sorts of helpful
information
and ideas from other's replies and from my own observation, I was pretty
sure we
were dealing with a subareolar abscess in mom's right breast.  The mom and
I were both on the phone first thing Monday morning trying to convince a
doctor, any doctor, to see her (it took a LOT of convincing, I'm sad to
say).
Finally she got an appt Monday afternoon with a surgeon and she invited
me along (made my day, my week, etc.!).  He immediately did an U/S of the
breast (I was so excited!) and found NOTHING but very densely engorged
tissue --
go figure!  >

Engorged tissue: Engorgement seems to be a word that has thus far escaped
clear definition. Each time we use the word, we could each easily be
referring to a horse of a different color.

I have the impression that such lack of definition has led to a great deal
of misunderstanding in regard to the lactating breast.

Would the swelling that accompanies mastitis be 'mastitic engorgement'?

And for that matter, both non-infectious and infectious mastitis have
swelling as a symptom, so even 'mastitic engorgement' could be two horses of
two different colors!


<I was SO hoping to find an abscess that could easily be drained on
the spot, she could finally relieve the engorgement in that breast, angels
would sing,
and they would all live happily ever after, but it didn't happen.  It was
all just very densely
engorged tissue.>

There it is- that "horse of a different color" again.

<Doc tried a random aspiration (sans local anesthetic) by just poking a
syringe> (Needle???)
in here and there and pulling back the plunger (Ouch!!!) hoping for at least
a little pus for
culturing, but found nothing but blood.>

Wow! tissue poked with a needle, now yielding blood! Perhaps injuring a
few blood vessels? Certainly not a pocket of blood, (at least yet) from the
description. But certainly doesn't add any clarity to the use of the word
'engorgement'.


< He offered to prescribe a stronger antibiotic than the 500 mg qid
Ampicillin she had been taking for the past four days.>

So, infection is definitely being considered as the cause of the swelling.
So, an 'engorgement horse' of a different color seems to have emerged from
more common usage.


<She has had wonderful success pumping her L breast 8x/24h; I even wondered
if those MER's were exacerbating the congested breast.>

Congested. A more familiar concept definitely association with an abnormally
"crowded" situation.


<This is what is known as a caked breast, I suppose?>


An older term, but descriptive. At least a horse of a whole different color
than the engorgement that still often seems to be afflicting many mothers at
10 days.


Understanding the physiology of breast swelling is still far from a science.
When the science develops further, I hope the number of terms will
increase to facilitate identification of "horses of many different colors."


Not much help in shedding light on the solution of Debbie's dilemma, but I
guess I was reminded of Diane Wiessinger's advice to "Watch your language".


Jean
***************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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