OBSTETRICS.
Treatment of Chronic Mscess of the Breast and Milk Fistulee.—Em-
ployment of Iodine Injections. [Cases under the care of Mr. Birkett.]
—We have been much gratified by watching the result of the treatment
pursued by Mr. Birkett in several cases of chronic inflammation of the
breast, attended with sinuses and long continued suppuration, which
have recently been under his care. This form of disease, as the result
of neglected milk abscess, falls, we have no doubt, pretty frequently
under the observation of most of our readers, and is often very trouble-
some to cure. The breast becomes affected with solid oedema, the sinuses,
usually running in several directions through and behind the gland, are
most difficult to close, and, by the constant discharge from them, the
patient’s powers become much undermined. In an extreme case of this
description, which had lasted for many years, we not long ago saw Mr.
South perform excision of the whole diseased mass, believing that to be
the shortest method of getting rid of a useless part, which had become
a serious evil to the patient. The remedies usually employed, are, as it
is well known, support to the part, and the laying open freely of the
sinuses, or the injection of them with various irritating fluids. Mr.
Birkett’s treatment consists in the employment of iodine taken internally,
applied as an ointment over the tumor, and used also as an injection for
the sinuses, whilst at the same time the part is carefully supported and
subjected to gentle pressure by means of a bandage. The power of
iodine, as a means of exciting the absorption of inflammatory products is
well known j and, as an application to the lining membrane of sinous
abscesses, it has for some time been employed on the Continent, and,
less generally, in this country also. The success which has attended
Mr. Birkett’s method of treatment has been, as the following case will
show, most encouraging.
Elizabeth Wiles, aged 26, the wife of a farm laborer, was admitted
January 6th, 1853. Three years ago, while suckling, she suffered what
from her description would appear to have been an attack of acute in-
flammation, both of the left mammary gland and of the surrounding
structures. Her child was then eleven months old, and the disease ap-
peared to have been excited by inflammation of the lymphatics of the
arm from a sore on the finger. It was so severe as to confine her to bed
for ten weeks, and to necessitate the employment of great number of
leeches. It ultimately subsided considerably without having occasioned
any abscess. The swelling, however, never quite disappeared, but after
a time it again began to increase; and a year subsequent to the first at-
tack, a large chronic abscess had to be opened, which never afterwards
healed. In September, 1852, she was again confined. The disease of
the breast having resisted the persevering treatment of several practition-
ers in the town where she lived, and her constitutional powers being evi-
dently very much reduced by the long-continued and profuse discharge
of pus which it produced, she was ultimately recommended to come up
to town, in order to have Mr. Birkett’s opinion as to the propriety of
excision. On admission, she was emaciated, and of a somewhat hectic
appearance; the discharge from the sinuses was very profuse, and the
whole breast much indurated. She was then suckling with the right
breast.
Mr. Birkett advised her to wean her infant, and ordered her to be
confined to bed, with a poultice over the part for a few days, until the
state of excessive irritation which appeared to exist had somewhat sub-
sided. He then prescribed for her the following mixture :
R. Potassii iodidi gr. iij., infus. gent, ^i., ter die sumend.
The breast to be wrapped in lint spread with ung. plumb, iod., and
the whole supported by a bandage carried round the shoulder. On the
23d, the symptoms having already begun to amend, the injection of all
the sinuses with the tincture of iodine (London Pharmacopoeia) was per-
formed by means of a tube carried to the end of the sinus. The treat-
ment as above was persevered in, and after the expiration of a week the
injection was repeated, and again after another space of two weeks. At
present, March 15, the sinuses are quite healed; the gland has been
reduced very nearly to its natural size, and the patient has gained in
general health to a point beyond what she has enjoyed since the com-
mencement of the disease. With the exception of the first few days,
she has been allowed to be out of bed the whole time, and full diet has
been allowed her. On each occasion that the injection was used, it pro-
duced considerable smarting pain, and was followed by a temporary in-
crease of swelling and discharge, which very quickly subsided.
We scarcely need point out the advantages of the above plan of treat-
ment over the old method of laying open the sinuses. In the latter the
incisions have to extend wide and deep, and they involve considerable
hemorrhage, and, for a time, increased constitutional irritation and great
discharge of pus. Other cases of a similar nature lately brought under Mr.
Birkett’s charge, in which the iodine cure has been practised, were the
result of common milk abscess, from which the above, as will be seen,
differs in some particulars.
Prevention is better than cure, and, as we believe, there are few dis-
eases more thoroughly within the reach of prophylactic measures, than
is milk abscess, we cannot dismiss the subject without saying a few
words on that head. The history of this disease is in most cases easily
told. A woman of delicate skin is confined, perhaps for the first time;
lactation commences, the cuticular investment of the nipple, irritated by
the mouth of the child, becomes cracked and fissured, each application of
the infant to the breast occasions torment to the mother, and she avoids
it as much as possible. The child is allowed to suck only on the sound
side, the milk accumulates in the other breast, and slight inflammation
is set up, to be aggravated by the increasing dread on the part of the
patient of the natural method of relief, the evacuation of the milk. An
abscess is the result. Now, how was all this to be avoided ? In most
cases pregnant women consult their medical advisers on sundry little
points some time before their confinements. Let him on those occa-
sions enquire as to the state of the nipple ; and should the skin be found
to be delicate, the daily application to the part of an alum wash, decoc-
tion of oak bark, or some other astringent, should be recommended. By
such means the skin may be hardened, tanned in fact, and rendered
just as capable of resisting irritation as that of the finger. In other
cases milk abscess depends on the non-development of the nipple. The
surgeon should take care that a shield be provided beforehand, and that
his patient knows how to use it properly.
But, supposing that, with the greatest care, abscess has proved un-
avoidable, there are still measures by which the disease may be prevented
from passing into the deplorable condition in which we have noted that
the patient in the above case came into Mr. Birkett’s hands. We have
repeatedly heard Mr. Paget observe, that, among his out-patients at St.
Bartholomew’s, he never has any opportunity for trying the various
vaunted injections for the cure of sinuses in the breast, because the latter
always heal of themselves. We have very carefully watched Mr. Paget’s
practice, in which mammary abscesses are very common, and can most
fully confirm this statement. His treatment consists in the free evacua-
tion of all collections of matter, and in the internal exhibition of tonics.
A generous diet of meat and beer, with full doses of quinine or iron,—
such are the remedies under which improvement in the local and general
condition of the patient seldom fails to become rapidly manifest. It
must, however, be admitted that the applicants, as out-patients, do not
include a small class of peracute cases in which the symptoms are often
too severe to allow of the patient’s leaving her bed. The systematic
avoidance of antiphlogistic measures in the treatment of local suppura-
tive inflammations is daily becoming more and more common, and in no
respect has modern practice more strikingly advanced than in this. It
affords, too, a good illustration of the application of minute pathological
research to actual every-day practice. Those of our readers who had
the good fortune to hear Mr. Paget’s lectures on inflammation, delivered
before the College of Surgeons three years ago, will remember how un-
willingly the Professor admitted the existence of any increase in forma-
tive power in that condition. This view, founded as it was on theoretic
reasoning, and microscopic observation of the process, has since been ad-
vocated by other pathologists, including some of the German school, and
it is interesting to observe how, upon emperical recommendations
merely, the line of practice which it would suggest is rapidly coming
into vogue.—London Med. Tim.es and Gaz.