PUERPERAL MASTITIS.
Acute mastitis occurs so very fre quently during the puerperium that the affection under other conditions is relatively rare. Of seventy-two cases observed by Nunn, fifty-eight occurred during lactation, seven during pregnancy, and seven separate from these conditions. Bryant saw seventy-nine cases during the puer perium, two during pregnancy and twenty-one outside of these condi tions. I have seen in all fifty-six cases (almost all in my clinic on account of abscesses); in forty-four cases the affection had developed during lac tation (usually unilateral, bilateral in a few cases), in four cases during pregnancy, and in six cases in unmarried or married, but non-pregnant or non-suckling, women.
There are not statistics to show whether mastitis is more prevalent in lying-in houses than in private houses. Winckel writes, as follows, as regards the frequency of puerperal mastitis, in the Dresden Lying-in Institute: " Of 2300 nursing women, of whom 918 were suffering from disease of the breasts, I found 136 cases of parenchymatous mastitis; i.e., 6 per cent. of all the nursing women and nearly 15 per cent. of all suffering from affections of the breast; of those affected with mastitis, there were as many blondes as brunettes." Primiparce are more disposed to mastitis than multiparse. Winckel found the following proportions: Primipara3 67.6 per cent.; MuRipens! 39.9 per cent.; Multiparte, with rapidly re curring pregnancies, 1.5 per cent. Mastitis is more frequent among suckling than among non-suckling women; thus: Ed. Martin in 150 cases, only 8 or 10, Winckel in 60 cases, only 1, in which the patient suffering from mastitis was not nursing.
Puerperal mastitis is more frequent on the right.than on the left side, and is very seldom bi-lateral. By summing up the cases in the table given by Hennig of mastitis and abscess, we find 156 cases of the right gland, 131 of the left and 37 bi-lateral. Winckel noticed in 141 cases, 50 of the right, 68 of the left, and 23 of both glands. Bryant saw 55 cases of the right, 30 of the left, and 5 of both glands. The statistics of these three give: 261 of the right, 192 of the left; and 65 of both glands. As
a rule, only part of the gland is afttcted, and most frequently the lower and the lower external part. Of 154 cases seen by Winckel, The same result is shown by the smaller statistics of Nunn. Mastitis usually begins during the first four weeks after labor, and as a rule in the second half of this period (Bryant, Nunn, Winckel). Mastitis very frequently arises from lesions of the nipples caused by nursing. Accord ing to Winckel, mastitis sometimes appears within the first twelve hours after the injury to the nipple, but more frequently within the first week, and most frequently on the third or fourth day after it.
Etiology. —It was formerly thought that emotional disturbances, colds, blows and pressvre most frequently caused puerperal mastitis, and these causes are at all events worthy of consideration in typical cases; of more consideration is the view that the irritable breast of puerperal women may be the result of milk stasis in certain parts of the gland. I will not deny that this may occur; from some unknown cause, the milk may coagulate in certain excretory ducts, causing an obstruction by which stasis of milk and inflammation around the tensely distended lobules may result; or, in consequence of greater laxity of the muscular tissue, or of incomplete emptying of the organ by the child, a great deal of milk may remain in certain cases and the circulation in the gland be interfered with. Still, when we so often see the women, in whom, for some reason, nursing has been interrupted, have no abscesses or inflammation — cases in which there is only firm tension, and then absorption of the retained milk—it seems doubtful whether retention of milk is so often the cause of acute inflammation as has been supposed. I believe therefore that Roser is entirely right when he maintains that the retention of milk is not the cause but the result of the inflammation, since the excretory ducts of some lobules are displaced by the inflammatory swelling. Most obstetri cians are now inclined to this view, and regard puerperal mastitis as being in direct relationship to disease of the nipples.