Whatever method he adopted, the practitioner should make a careful daily examination of the breast for the oedema and pitting of the skin which warn him that pus has formed, and one drawback to the use of coloured ointments and applications is that they more or less hide the skin and may prevent the early detection of this important sign. As soon as pus has formed it is neither kind nor fair to the patient to delay incision. There is no hope of its becoming absorbed, and if tempted to allow evidence of pointing of the abscess to present itself before an incision is made, the practitioner should remember that while the suppurative process is approaching the skin surface it is spreading at an even more rapid rate through the less resistant tissues in the depths of the gland, so that an originally small pocket of pus is being converted into a large branching and loculated cavity which may take in healing weeks or even months in place of a few days.
A suppurating breast should always be opened under an anaesthetic and with strict antiseptic precautions. The incision should be an inch to an inch and a half long, and should lay the abscess cavity open and not merely puncture it. It should run radially from the nipple, and be placed preferably at the most circumferential part of the abscess. The finger should be introduced through the incision and should break down any septa that are found so as to throw the cavities into one. If there is extensive suppuration it is more satisfactory to make two or three openings rather than to attempt to drain the whole area through one incision, no matter how large or how favourably placed. The cavity should be washed clear of pus and debris with r in 2,000 Perchloride or drachm to the pint Lysol, or Creolin solution delivered from a douche can through an ordinary vaginal nozzle into the cavity. When this has run off, the whole of the cavity and its recesses should be loosely packed with iodoform or double cyanide gauze wrung out of antiseptic solution, a thick layer of cotton wool put on over the entire breast, and a firm binder or bandage applied.
The packing should be removed next day and a fresh one inserted, and this should be repeated until the cavity has granulated up, a process which takes place in a wonderfully short time as a rule. Sometimes the breast itself escapes infection, but an abscess forms behind the gland. This should be incised early along the lower border of the breast, otherwise its spread in the loose retromammary tissue will be very rapid.
Chronic mastitis is found occasionally as the result of injury. More commonly it arises in women who have nursed children, probably as a late result of an indolent infection during lactation. The breast is hard, knotty and tender, and the axillary glands are usually enlarged. The condition may be confounded with scirrhus, but on compressing the breast between the flat hand and the chest wall it is evident that a true tumour is not present. The most satisfactory treatment is to strap the breast either with adhesive plaster or with a mercurial plaster. This usually effects a cure if persisted in for a few weeks. The plaster should be removed and the breast restrapped at least once a week.
A tuberculous mastitis is sometimes observed, and such cases seldom recover without amputation of the breast. It is always worth while, how ever, to try the effects of small doses of tuberculin (say mg.), coupled with the usual hygienic treatment adapted to tuberculous lesions.
In some cases of chronic mastitis occlusion of one or more ducts takes place with the subsequent development of a cystic swelling (galactocele). If the cyst does not subside under strapping, it should be punctured, or a piece of its wall excised and the cavity packed.