LETTER XXXVI.. Inflammation of the Breast.

INFLAMMATION OF THE BREAST.

Structure of the Mammary Gland—Nature and Causes of Inflamed Breast—Means of Prevention and Cure.

It is very common in midwifery-practice to encounter swelling and inflammation of the breast, more commonly within a few days of delivery. In the majority of cases, this inflammation is managed without much difficulty; but in some cases it would appear that the part must suppurate, or break, as we say, forming what we call the mammary or milk abscess. This is one of the most troublesome things women are ever brought to endure; but however much pain and discomfort milk-abscess may cause the patient, it never kills; and yet the patient may be kept for months in the sick room, suffering from the affection more than tongue can tell.

Inflammation of the breast may come on at any time during lactation. It is more common, however, in the earlier than the later parts of the period. The nursing mother cannot, however, at any time be too careful in all matters pertaining to health, since a little imprudence is sufficient, in many cases, to induce this affection. In multitudes of instances it has been brought on by some apparently trifling carelessness, when, with a little forethought and self-denial, perhaps, months of pain, suffering, and discouragement might have been avoided.

In order to understand the management of the female breast during lactation, it is necessary that we should know what it is, its anatomical structure, and its physiological functions.

In structure, the breast is a conglomerate gland, and consists of lobes which are held together by a dense and firm cellular tissue; the lobes are composed of lobules, and the lobules of minute cæcal vesicles, the ultimate terminations of the excretory ducts.

Near the center of each breast there is a small projection of the tegumentary coverings, constituting what is called the nipple; this is surrounded by an areola or border, having a colored tint.

Before conception, this areola is of a pink color; after conception it assumes a brownish hue, which deepens in color as pregnancy advances. This brownish tint continues through life.

About the nipple there are a considerable number of sebaceous follicles, which secrete a peculiar fatty or oily substance for the protection of the delicate skin about the part. During the period of nursing, these follicles become increased in size, having the appearance of pimples projecting from the skin. The sebaceous or fatty secretion from these follicles serve, during lactation, to shield the delicate part from the action of the saliva of the child’s mouth.

The milk-tubes, or excretory ducts, as they are anatomically named, are usually ten to fifteen in number; and as many as twenty-one is said to have been found in a single breast. These tubes commence by small openings at the apex of the nipple, and passed inward parallel with each other toward the central part of the breast, at which place they become enlarged, and branch off in every direction throughout the mammary gland; these communicate in some way with the blood-vessels of the part, and, by a peculiar and wonderful provision of nature, the milk is formed from the blood within them. Among and about the milk-tubes, there are many adipose cells, more or less numerous, and more or less filled in different cases, giving to the part its peculiar rotundity and softness.

The milk-tubes are capable of supplying a quantity of milk greater or less, as the case may be. With some persons, an immense quantity is secreted; at a single time a pint or more of milk may be drawn with a breast-tube from a single breast. But we are not to suppose that all this amount of milk is contained within the ducts at the time we commence drawing it; a small portion may be there, but the greater part is secreted after we commence. After a time the power of the gland to produce it being exhausted, the milk ceases to flow; but after nature has been allowed to rest an hour or two, it again recovers its milk-giving power, and is ready to furnish it liberally, as before. A good cow has an udder, which, if we were to cut it off, could readily be put into a small pail; and yet this same cow is capable of giving milk enough at a single milking to fill two or three pails of the same size. This shows us how admirably fitted these organs are for pouring out that material which is so necessary for the sustenance of the young: a material, simple as it may appear, yet one which art and science, with all their boasted pretensions, cannot at all imitate. The chemist can tell us that milk is composed of a mixture of water, albumen, casein, and oil, which we call cream; but all the chemists in the world cannot make a drop of milk, or any thing that, in physiological properties, will at all compare with it.

The breasts are abundantly supplied with nerves and blood-vessels, and it must be evident that so great a functional power as that which is exerted by the mammary gland during lactation, must be supported by a great quantity of blood and nervous force. Hence it is, that during nursing, the breasts are supplied with a much larger amount of blood, and are much larger in volume than at other times. In this wonderful fact, as in many others of the living body, we see the ever-beautiful order of nature, in adapting her means to her ends. If every thing happened by chance, we might just as soon find the breasts containing less blood when milk is needed, as more. But the doctrine of chance is too palpably absurd to need comment.

Symptoms of Inflammation of the Breast.—A day or two, or a few days after delivery, we often find the patient apparently so well and in such good spirits that we conclude there is no further need of our attentions. But in a day or two more we are sent for in great haste perhaps. We go, and find the patient downcast, dispirited, and evidently enough sick. We inquire as to what has been the matter. The patient tells us she has been attacked with a chill, in spite of which she could not get warm for one or two hours, or perhaps longer; just such a chill as would be experienced in the coming on of an ague, or any other fever, or some inflammation.

“Inflammation of the breast,” according to a very accurate writer, Dr. Burns, “may be divided into three species, according to its seat—the sub-cutaneous cellular substance, the fascia, and the glandular substance.

“It may take place at any period of nursing, but is most readily excited within a month after delivery. It may be caused by the direct application of cold, engorgement from milk, the irritation of excoriated nipples, mental agitation, etc. Some have the breasts prodigiously distended when the milk first comes, and the hardness extends even to the axillæ. If, in these cases, the nipple be flat, or the milk does not run freely, the fascia partially, in some habits, rapidly inflames. Others are more prone to have the dense substance, in which the acini and ducts are imbedded, or the acini themselves, inflamed.

“The sub-cutaneous inflammation, if circumscribed, differs in nothing from a common phlegmon, and requires the same treatment. It is not easy to resolve it, but a tepid poultice will do this, if it can be done; if not, it brings it forward. When it bursts, the poultice should be exchanged, in a day or two, for mild dressings.

“The inflammation of the fascia, if light, is marked by some little tension of the breast, with erythema of the skin over the affected portion. There is considerable fever, but not much pain, and the disease is likely to yield to tepid fomentations and a purgative, if the milk can be drawn off freely. If the fascia be more extensively or severely inflamed, the breast swells quickly, and this distention adds to the disease, which, indeed, is often caused, at first, by distention of the fascia. The pain is great, and the fever considerable. The inflammation never is confined to the fascia, but is communicated either to the sub-cutaneous cellular substance above it, or to the parts below it, usually to the former, and after, at the same time, to the latter.

“When the deeper parts are affected, the inflammation may be more or less prominent in the lactiferous ducts, or a cluster of acini; or often in that dense, peculiar kind of substance, which is their medium of union, or in those fatty packets which are sometimes met with in the gland. Often it seems to commence in one of the sinuses near the nipple, and, spreading, involves the surrounding cellular substance. In this case, it becomes prominent, and seems as if quite superficial. Milk is not secreted by those acini which have suffered. Matter presently forms, and spreads under the fascia with much distraction; and when, at last, after long suffering, the abscess gives way, much pus is discharged, with pieces of slough, chiefly consisting of portions of fascia. Usually, there is a considerable degree of fever attending the complaint, and the pain is often severe, especially when the breast is extensively affected.”

Treatment.—A great variety of methods have been adopted for the prevention and cure of inflamed breasts. This affection is often brought on, doubtless, by carelessness, neglect of drawing the milk from the parts sufficiently often in the beginning, excessive fatigue, seeing too much company, too much care and anxiety of the mind, overfeeding, hot and stimulating drinks, feather beds and pillows, overheated rooms, want of attention to bathing and cleanliness, and last though not least, excessive drugging; these are among the more prominent of the causes of inflamed breasts.

The first and most important consideration, then, is to avoid, if possible, the disease. Mothers, and all of you who hope or expect to become mothers, if you wish to save yourselves a great deal of needless pain and suffering, a great deal of restlessness at night; if you wish to avoid one of the most troublesome and disheartening affections to which the female system is ever liable, I warn you in the strongest feelings of sympathy and regard for your sex, that you avoid, so far as is possible in the nature of things, the CAUSES of this terrible disease.

But some have poor, feeble, scrofulous constitutions, and cannot by any possibility avoid the inflammation of which I am speaking; and, do what we will—the best that, in the nature of things, can be—the breast must, I think, in some cases inflame, suppurate, and break. An accidental blow, likewise, so slight that it would scarcely be felt upon almost any other part of the system, may cause a mammary inflammation and abscess. And, worst of all, to think of many a poor mother who has so poor a habitation, is so much oppressed by the cares and perplexities of domestic life, and has such poor care and nursing that she is always in great danger of suffering with inflamed breasts.

The treatment of this affection, therefore, is a matter for the serious consideration of both parents and physicians; and, as I before remarked, a great variety of methods have been adopted for this end.

We should remember that we are to treat an INFLAMMATION, and that the plain principle of treating all inflammations, of whatever grade or kind, when of acute character, is the antiphlogistic or anti-inflammatory plan. By what means and to what extent to use these means, are circumstances in which the skill, tact, and good judgment of the physician are to be exercised.

A very common error has been to treat too much locally in this disease. This is, in fact, a very common fault in medical practice generally. I have no doubt that many an inflamed breast has been rendered worse than it otherwise would have been by the too great amount of local means employed. In many such cases, doubtless, the breast has been made worse than it would have been had no treatment whatever been employed.

As soon, therefore, as the patient begins to experience a chill coming upon her, with pains in the back, limbs, etc., together with a general uneasiness and restlessness, and, perhaps, with an inflammation already commenced in one or both of the breasts, no time should be lost in setting at work resolutely to combat the approaching evil. The sooner we act, and the more prompt and resolute in the treatment, the greater the chance of preventing an abscess. We give the rubbing wet-sheet, if there is not already too much fever, the tepid shallow-bath, with a good deal of friction; a general cold bath, if the patient is not too weak; the packing sheet, the wet girdle, wet compresses upon the breasts, injections of tepid water, and follow up the applications as much and as often as the symptoms may demand. Above all, the patient should not be worried by a multitude of ignorant and careless, though, perhaps, well-meaning friends, who each and all insist that some particular poultice, or some favorite “cure-all” of theirs will certainly arrest the difficulty, if the patient will but condescend to use it, and that if she keeps on with the water, it will certainly cause the breast to break. How exceedingly foolish, ignorant, and prejudiced are the multitude in regard to these things! Every practitioner of water well understands how much we have to encounter in society, because of the prevailing ignorance of the most common remedial uses of the greatest and most abundant of all curative agents which God has given to man.

As regards the temperature of the applications, local and general, we do no violence to the system. Should we persevere sufficiently, we could cure almost any fever or inflammation with water at 80° Fah., a temperature so mild that the most delicate child can bear it.

One thing in particular should be remembered: the patient should not be bundled up closely, and have a great deal of warm bed-clothing, under the impression that a cold will be taken if such measures are not adopted. We almost always find patients heating and injuring themselves in this way. But it should always be remembered, that when a fever or inflammation is already present, it is not possible to take an additional cold.

As for local applications upon the breasts, fine wet linen cloth should be used constantly. As to the temperature, I think it best to consult the patient’s feelings merely. It is, perhaps, best to alternate somewhat; sometimes to apply warm or tepid cloths, at other times cold. I think a change is often good; at any rate, we should keep the parts constantly wet.

The wet cloths are covered with dry ones, or flannels, if necessary; but if there is great heat in the part, it is best to leave the compresses uncovered, so that by evaporation a much greater amount of heat may be thrown off. Sometimes the breast becomes so heavy and painful, that it is a great comfort to the patient to have it suspended in a sling.

I have already hinted how important it is to keep the milk well drawn. The mouth of an adult person is one of the best means, and the infant is often able to do good service in this way. Some get along pretty well with a tobacco pipe. But the instruments generally found in the shops are illy suited to their object. One form, the suction-pump, is an invaluable piece of mechanism, provided the glass that fits upon the breast be of the right shape, and have an opening sufficiently large to admit a man’s thumb. Generally, they are much too small, causing a good deal of pain when used; but if they are of the right make, they will draw the breast with more comfort and less pain than the infant itself.

Before the breasts are drawn, they should be well washed, for this will always help the milk to flow; and in connection with this subject, there is one highly interesting and instructive fact in regard to bathing. Thus, a patient may be in a condition in which, in consequence of the inflammation present, no milk whatever can be obtained. But we give the patient a good ablution of the whole body, even a simple tepid-bath, and directly we may succeed in getting milk; and in some instances it is made actually to drop of itself from the breasts. Even the washing of the breasts alone will sometimes cause it thus to flow.

Should an inflamed breast ever be opened after the matter has once formed? The most common practice has been to do it. Dr. Gooch, however, who is high authority with the profession, speaking of this disease in that state in which the matter approaches the surface, says: “Will you open the abscess? If you do, you will relieve your patient from suffering, and by the evacuation of the matter the constitutional disturbance ceases; but the wound will not heal so soon, and the maturation of the abscess will not be so complete as if the whole process were left to nature.” I have myself opened them at the request of patients in some instances; but I have become convinced that it would have been better, in the end, not to do it.

Dr. Burns tells us—although he recommends opening the abscess—that the puncture is liable to be followed by a troublesome oozing of blood from the wound, and that in one instance he knew the hemorrhage to prove fatal.

After the abscess has burst, there is for some time a discharge of purulent matter, which is not unfrequently mixed with milk. The utmost cleanliness should be observed, and a considerable amount of general, as well as local treatment should be kept up until the healing is fully effected.

Thus, then, in the use of water, locally and generally applied, together with the proper adaptation of the other hygienic means, I consider that we have a remedy which far surpasses all others in that troublesome affection of which I am treating; a remedy which, if it cannot always cure the inflammation without an abscess, will yet so much mitigate it, so much promote the healing, and so much support the patient’s strength, that mammary abscess, if it must occur—and I think, do what we will, in some few instances such must be the case—it is yet stripped of its greatest horror, and rendered, generally, a comparatively trifling affair. Such has been my own experience, and such, I think, will be found to hold good wherever the water-treatment is faithfully and skillfully applied.

Dr. Burns has given us a sad picture of what not unfrequently results from mammary abscess; and that the reader may have, on good authority, an account of the sad condition which sometimes results from the affection, I quote his own words:

“It sometimes happens, if the constitution be scrofulous, the mind much harrassed, or the treatment not at first vigilant, that a very protracted, and even fatal disease, may result. The patient has repeated and almost daily shivering fits, followed by heat and perspiration, and accompanied with induration or sinuses in the breasts. She loses her appetite, and is constantly sick. Suppuration slowly forms, and perhaps the abscess bursts, after which the symptoms abate, but are soon renewed, and resist all internal and general remedies. On inspecting the breast at some point distant from the original opening, a degree of œdema may be discovered, a never-failing sign of the existence of deep-seated matter there, and, by pressure, fluctuation may be ascertained. This may become distinct very rapidly, and therefore the breast should be examined carefully, at least once a day. Poultices bring forward the abscess, but too slowly to save the strength, and, therefore, the new abscess, and every sinus which may have already formed or existed, must be, at one and the same time, freely and completely laid open, and, so soon as a new part suppurates, the same operation is to be performed. If this be neglected, numerous sinuses form, slowly discharging fetid matter, and both breasts are often thus affected. There are daily shiverings, sick fits, and vomiting of bile; or absolute loathing of food, diarrhea, and either perspiration or a dry, scaly, or leprous state of the skin; and sometimes the internal glands seem to participate in the disease, as those of the mesentery, or the uterus is affected, and matter is discharged from the vagina. The pulse is frequent, and becomes gradually feebler, till, after a protracted suffering of some months, the patient sinks. It is observable, that often, in those cases which seem to depend on a constitutional cause, and when there is great debility, the sinuses heal rapidly, after being laid open, but a new part instantly begins to suppurate. Internal remedies cannot be depended on here, for they cannot be retained. If they can be taken, they are those of a tonic nature that we would employ, with opiates to abate diarrhea and procure sleep.”