SEQUELE OF MASTITIS.
After every acute or chronic abscess of the breast, fistulae may remain. The immediate causes of these fistule are faulty escape of pus on account of a too narrow opening or valvular closure of the same, fungous or un healthy granulations in the abscess cavity; anemia, great general weak ness and general diathetic conditions are the remote causes. Fistulae of the mamma usually discharge thin pus, seldom milk, and, as a rule, lead to sinus-cavities in or behind the gland. When of long duration, ab scesses behind the breast may lead to suppuration of the pectoralis major muscle and of the periosteum of the ribs, and even to suppuration of the intercostal muscles and the pleura; the last, however, is very rare, and in such cases there would be pleural adhesions from the purulent process and pneumothorax would result. Long duration of these fistulae weaken the patients very much; they become emaciated, often have a remittent fever, night-sweats, loss of appetite, become exceedingly irritable and are mentally depressed. If nothing unusual happens, the process may go on for months. If such patients are disposed to pulmonary tuberculosis, it may seize this opportunity to develop rapidly.
As regards the treatment of such fistulae, it is usual to first cauterize with nitrate of silver and then to make injections of diluted or concen trated tincture of iodine, carbolic acid solutions, etc. Many of these fis tulae may be cured by inserting drainage tubes and using coincident compression. It seldom happens that in otherwiie healthy women, all these measures fail to effect a cure; in many of the cases which have come to my clinic, the fistulae had existed unchanged more than a year, without there being any caries of the ribs, as is so much feared in these cases. The reason that such fistulae do not heal is, in my opinion, a purely mechanical one; the thickened abscess-wall, which is bound to the wall of the thorax, can only slowly contract and shrink. In all the cases of long-existing fistuhe of this kind observed by me, the reason for their existence was always found in abscess-cavities, which lay, for the most part, behind the mamma. The sluggish fungous granulations of all such cavities show no inclination to grow together; their secreting sur faces are covered usually with a thin layer of epithelium, which never cor nices, though its epithelial character is evident, since the cells never coalesce and there is no vascular connection between them. When such abscesses heal, it is only through shrinking of the walls; but such shrink age is difficult on the unyielding chest-wall, on the anterior surface of the pectoralis major muscle, and the abscess remains for a long time in the condition of one or several indurated fistula3.
Formerly in such cases I made very large incisions in the periphery of the gland, following its circumference, so that the under surface of it had sufficient play to contract. But a long time was required for healing
unless the whole cavity was so intensely irritated by such remedies as liq. ferri, turpentine, etc., that the old granulations were thrown off and new ones were formed. In two cases which I treated about a year ago, I split the fistulae so extensively that the abscess cavities could be seen to advantage; then I scraped out the granulations with a sharp spoon as completely as possible, excised the fistulous opening in the skin, washed the cavity for a long time with a three per cent. solution of carbolic acid, sutured the incision in which I had placed a drainage tube, then placed over the whole a compressing antiseptic dressing, which remained for five days. At the end of this time, the drainage tube was removed, a second dressing applied and allowed to remain five days. Healing ap peared to have taken place by first intention. Unfortunately, as with other cold abscesses, this cure did not remain complete; in the course of a few weeks other small fistulae appeared, which did not secrete as much as the first, and disappeared only after many months.
Galactocele and cyst fistuhe will be treated of in a later section. Indu ration sometimes remains for a long time after mastitis, especially in those cases in which there has been no abscess formation. These indu rations differ from " adeno-fibromata," which are said sometimes to develop in the breast after the puerperium, in that they are less hard and less clearly defined than the neoplasms, and in that after iodine embroca tions and compression they disappear, while the new growths remain stationary.
Atrophy and disfigurement after very extensive suppurating mastitis are, unfortunately, not infrequent. In well-nourished women so much adipose tissue will usually be formed in the course of a year that the disfigurement will only be slight, and sometimes scarcely noticeable. The cicatrices caused by the incisions usually disappear entirely.
[Puerperal mastitis need, nowadays, rarely extend to suppuration. It is always possible to forestall any extensive phlegmonous process, and even in its beginning we are usually able to check it. A valuable paper published by Harris of New Jersey, in the .American Journal of Obstet rics, for January, 1885, called the attention of the profession to the manner after which mastitis may be prevented or checked in its course. The same method was, at the time, being used in the New York Mater nity hospital with the very best results, and under its uniform use we never, at this institution, have occasion to interfere surgically with the puerperal breast. The method depends simply on applying systematic and equable pressure to the mamma, and on absolutely prohibiting any manipulation whatsoever. The compression bandage used, and remarks in connection with it, will be found in Vols. I. and IV., of this cyclopze dia.—En.]