CELE.
It is very seldom that there is entire absence of milk secretion (agalactia) after delivery; it only happens when there is complete absence of the glands. It is well-known, however, that, in poorly developed glands. milk-secretion is very slight, and that for this reason, especially, many women cannot nurse their children. Excessive secretion of milk after delivery is not always the result of abnormally developed glands, or of an especially strong constitution. It is frequently the case that weak, nervous women secrete a great deal of milk and thereby emaciate mark edly, although they eat well. For weeks and months there is sometimes a continual flow of milk from the breasts (galactorrhcea) of women who have either not nursed at all or who have ceased to do so early; this is especially frequent in slender, flabbily built women. According to Birkett, Montgomery saw a case in which the flow of milk continued for three years after labor, and after five years milk could be expressed from the gland, though there had been no new pregnancy.
Abnormal milk secretion has been repeatedly observed, though the num ber of authenticated cases has not grown very much of late, as most authors cite the same old cases over and over again. I have no observa tions of my own to offer, and can therefore only repeat what is already known. Beigel has collected all the known cases in literature. That milk can be expressed from the breasts of newly-born children, when the glands are swollen and tender, has already been stated. Th.Hiker has shown that the lactiferous ducts are dilated in these cases, and are almost cavernous. The secretion ceases without the use of especial measures. A case is mentioned by Will, in which milk flowed from the breast of a girl thirty weeks old, for some time. Baudelocque mentions the case of an eight year old girl, in the village of Alenton, who often applied a child, which her mother had just borne, to her breasts, by which means a milk secretion was established so that the girl was able to nurse the child for a long time. On October 16, 1783, the girl, from whose breasts a quantity of milk was at this time expressed, was exhibited to the Surgical Society of Paris. There were no other signs of puberty, except that, after the age of five years, she had a vicarious menstruation in the form of hemorrhage from the eyes (?) (This menstruation from the eyes is not very credible; furthermore, the nipples of an eight year old girl must have been extraordinarily developed, or the child could not have nursed; there must have been precocious development of the girl.) I will also cite from Beigel the observation of Dr. Carganico (1838). The fifty-nine year old wife of a working man nursed, without a coinci dent delivery, her nine months old grandchild. At the beginning the child was nursed by its mother, who was, however, compelled to wean it. The child became so restless, that the old woman, who had not men struated for ten years, placed it to her own breasts, after she had nearly satisfied its hunger by other means, to quiet it. Suddenly she felt pierc ing pains in both breasts, and on examination she found some drops of a milk-like fluid. The child was then zealously put to the breasts, with the result of producing such a free flow of milk that it was exclusively fed by her. Observations of moderate milk secretion in non-pregnant unmarried, and in childless married women are frequently mentioned, as also the occurrence of " milk-like" fluid in the breasts of very old women (one of eighty-two years, for example). Here and there mention is made of the secretion of milk in connection with uterine and ovarian tumors. In the tolerably large number of such tumors which I have seen, I have never witpessed such coincidence with abnormal milk-secretion.
Cases sometimes do occur in which the excretory duct of a portion of the gland becomes stopped up or is closed by adhesions. When the woman becomes pregnant and the gland becomes active, the milk cannot escape from the closed portion of the gland, but collects gradually in the lacteal sinus behind the nipple, and distends it more and more; this dis tension maybe very considerable without causing any pain, but simply a feeling of moderate tension. This condition is known as " Galactoeele or milk-cyst." The nature and time of its origin, which, as a rule, will be definitely given by the woman, the situation of the tumor and the well defined fluctuation, will, in most cases, leave no doubt as to the diagnosis. This manner of development of such retention milk-cysts is not frequent; I have never seen such a case, and other writers do not appear to have observed it often, since they all cite the same cases. Among these cases
we find some, the descriptions of which answer more closely those of subacutely developed abscess. One of the largest cysts of the kind, without doubt a galactocele, was observed by Scarps. A woman twenty years old, of strong constitution, with normally developed breasts, noticed a swelling of her left breast ten days after her second confinement; the more the child was applied to the breast, the larger the swelling became. In two months the breast was thirty-four inches in circumference and reached down to the left thigh. The skin covering it was unchanged, but the glands of the left axilla were somewhat swollen. Ten quarts of pure milk were evacuated with a trocar, chemical analysis showing that it did not differ from normal human milk. Suppuration, which con tinued a long time, followed, but the patient finally recovered com pletely. Two years later she had another child, but nothing unusual happened to the breast. Erichsen states that Walpy evacuated ten pounds of milk from a cyst in a similar case (Erichsen does not say where the observation of Walpy is published; perhaps it was a private commu nication; or can it be the above mentioned case of Scarpa? Beigel erro neously ascribes Scarpa's case to Birkett, who only cites the case from Scarps.) As to the fate of the milk in these cysts, it is thought that an oily, buttery, or even cheesy material is formed. It is possible that the milk in the gland may be changed into butter and cheese by simple thicken ing of the milk, in consequence of the absorption of the serum; and we may speak of " butter-cysts" and " cheese-cysts; " but these observations will scarcely bear analysis. I do not doubt that some oil, butter and cheese-like substances are found in mammary cysts; I will later speak of such observations, but I doubt that such are developed from true galac toceles, as above described. In the cases cited by Wrard, Birkett, and Beigel, from Martini, Brodie, Dupuytren, Layd, and Forget, I do not find it mentioned that the tumor, most often noticed in the later stages of lactation, grew larger from putting the child to the breast, and then gradually grew smaller; this could scarcely escape notice if such an ab sorption of water should occur as to cause the milk to become of a buttery or cheesy consistence. There is more probability in the case described by Astley Cooper, in which he opened a cyst in the breast of a thirty eight year old woman, one month after the birth of her last child, and evacuated " six ounces of white, coagulated milk, mixed with some yellow serum; " the woman had had the tumor one year before Cooper saw her. Certainly nothing can be said here of a change of milk into butter or cheese. The woman had had an abscess of the same breast after a previ ous confinement The cases reported by Velpeau cannot, convince me that the butter, cheese, and adipocere•like contents was thickened milk, in spite of the clear descriptions of the microscopical examinations made by Donn( and Lebert. That cysts of the breast contain fat in drops and crystals and shrivelled cells in various forms, is not to be wondered at. Qu(venne made a chemical examination of a cyst seen by Velpeau, and his language is very diplomatic: "des principes laiteux et butyreux, mais it ne pousse pas asses loin ses recherches pour les (numerer tons." The treatment of galactocele consists in opening and draining the cyst. I must refer to Velpeau's case of a " galactocele by infiltration," cited by many authors, and represented as though a galactocele had burst subcu taneously and the milk was extravasated into the meshes of the connect ive tissue. The matter is not so clear as that. Velpeau writes: " In a woman, thirty-four years old, who was confined fifteen months previously, and had weaned her child six weeks before, the right mamma swelled to about double its size, was of a hemispherical form, of spongy consistency, and painful for a few days; the skin was a little more glistening than on the other side, not reddened, but the whole breast was doughy. By puncture with a bistoury a considerable quantity of milk was evacuated, which clearly came from the meshes of the cellular tissue." Whence he draws the conclusion is not stated. It is very possible that a large milk duct was opened by the puncture, and the milk evacuated from the prob ably dilated ducts deep in the gland. That Velpeau took this view him self is very probable from the fact that he placed the case in the category of "lacteal engorgements." The tumor disappeared in fourteen days, after the administration of purgatives, and after blood-letting and baths.