By C. Wesselhoeft, M. D., Dorchester, Mass.

Among the numerous anomalies and digressions which nature often produces in the female organism, subsequent to parturition, those of the mammary gland are most conspicuous. To call them simply troublesome, would not sufficiently express their effect upon mother and child. The former suffers more pain and heartfelt disappointment, while the latter must, in many instances bear for life, the consequences of imperfect or arrested lactation on the part of the mother. This perhaps applies more widely to female infants. The first deplorable experiences of a physician, however brief his term of professional activity may have been, relate to the question of nursing, and his attempts at curing or palliating the distress of the manifold irregularities and frightful disturbances of this function often lead him nearly to despair in regard to medical aid.

I will here touch upon a few of the most common among the disorders of lactation, as they have presented themselves in my practice.

SORE NIPPLES. - This is perhaps the most common of nursing complaints, and, though apparently a simple disease, it is often the forerunner of more serious disorders. Considered by itself it is an excoriation of the skin covering the nipple; this partakes of the general character of the skin covering or surrounding the lips, anus, vulva, etc., approaching apparently the character of mucous membranes, into which it gradually merges down the mammillary ducts, as does the skin of the other organs just named. The epithelium is looser than that of the white skin more remote from the nipple; the underlying cutis is thick but more spongy than the cutis vera of other parts, and is closely interwoven with or supported by erectile tissue and pierced by the mammillary tubes. Now, a new excoriation of the surface cannot take place without affecting the underlying structures more or less.

The progress of the disease so well known to all, varies from simple soreness and slight fissures to deep cracks and suppurative destruction of the nipple. Before alluding to therapeutic measures, the causes of the complaint claim attention.

In the great majority of cases, the fault is supposed to rest with the infant, which by mother and nurse is accused of sucking too hard. Very likely it does; but if a mother's breast is constituted as it ought to be, that accusation could hardly be justified. With some women the milk undoubtedly flows more readily than with others. Everyone who has ever practised milking cows will have observed the difference in the degree of ease with which this operation is performed. Some cows are said to “hold back” the milk, while others “let it down.” I do not believe that the will of the cow (or in the above instance that of the woman) has so much influence as the state of the mind, such as fear of the milker, or other emotions. The nursing infant may be obliged to make efforts with such prolonged vigor as to cause soreness of its mother's breast, especially if she be a primipara. In good health this soreness will soon pass off.

Another condition for sore nipples is undoubtedly created by the habit of women to supply an imaginary, and still oftener a real natural deficiency, with pads of cotton and other more ingenious contrivances. It is astonishing to what an amount of physical torment many women will subject themselves for the sake of approaching the standard of an ideal of human development. What that is, may be readily seen at every shop window; a hideous distortion, a caricature resembling the perfect human figure no more than the peculiar little jointed dolls of wood and which are well adapted to fit clothes upon; an operation more difficult upon the natural curves and sections of the living body.

Many observations have established the fact sufficiently, as I believe, that sore nipples, leading to very serious destruction of the breast, are very rare among the poor Irish women wearing no pads, and very common, indeed almost unexceptional, among the more “stylish” residents of this part of the country. The shabby loose garments of a certain class of poor, together with their habits of endurance and consequent physical development, preclude diseases of the breasts to a great extent; while warm clothing, overtaxed nerves, and more delicate development are to be reckoned at least as one cause of sore nipples, as well as of many other complaints.

Besides pads and too vigorous nursing, there is undoubtedly another predisposing cause of sore nipples and other breast complaints but which does not become apparent quite so distinctly in sore nipples as in graver affections of the breasts. We all believe, or to speak more to the point, we know that there are certain constitutional taints, dyscrasies, or whatever we may choose to call them. A certain form or perhaps a complication of these dyscrasies, imparts to a patient a visible degree of unhealthiness, such as impure and rough appearance of the skin, pallor or redness of the face, tendency to skin diseases, leucorrhea, etc.

Concerning the treatment of this disease, I cannot boast of particular success; nevertheless, I am satisfied there are effective hygienic as well as therapeutic measures.

In what may be called simple sore nipples of primiparous women, but few remedial agents are required. Sponging in cool water, and the application of a light cold compress after nursing, has, in many instances, done all that could possibly be desired.

But in severe cases where years of vanity, neglect, or constitutional predisposition are the causes of trouble, more specific therapeutic agents are necessary. It would seem as hopeless to endeavor to counteract by moral suasion the pernicious effects of fashion, as to recommend, in the hackneyed language of our old-school text-books, to an invalid pauper, “a journey on the continent and a liberal diet with wine.” There are few diseases where local applications are so useful as in sore nipples. Next to cold compresses, where there is heat and dryness after nursing, Arnica, in the proportion of ten or fifteen drops of the tincture to a teacupful of water, has brought relief in cases marked by soreness and tenderness beneath the surface of the breast. It should never be used undiluted as is often the case, because the alcohol alone may make matters much worse. Besides this, Arnica tincture often produces a papular smarting eruption if applied to sound skin; this decidedly contra-indicates the use of undiluted, but shows the homoeopathic connection with sore nipples.

Calendula evidently vies with Arnica and may be used in the same way. Tannin, Tannin ointment, Glycerin and in fact many simple ointments may often be employed with benefit.

Among the numerous internal remedies often enumerated for this complaint, I have every reason to believe that Lycopodium and Silicea are highly important. The former where the fissures are deep and painful; the latter in subjects whom I had previously known to be predisposed to rapid or excessive suppurations and where the nipple was being destroyed by ulcerative process.

BROKEN BREAST FROM MALFORMATION OF THE NIPPLE. — The next affliction of nursing women, the dread of the patient and doctor, is the broken breast. While speaking of sore nipples, a picture of this terrible malady forcibly presented itself to my mind; and when treating a patient for the less severe disease, apprehension of the more severe form is invariably justifiable, though in many cases inflammation and suppuration originate without apparent external irritation. A description of this well known complaint would be out of place here; but regarding its predisposing causes, I hold certain views which, though neither new nor original, may elicit valuable observations on the part of my colleagues.

I doubt very much if inflammation and suppuration of the breast would attack a healthy woman without direct and violent external causes, such as foolhardy exposure to cold, or mechanical injury, etc. Next to these, the remarks concerning pads, etc., under the head of “sore nipples” may be applied to inflammation of the breast with the same amount of truth.

Aside from all other causes, and without regard to the constitutional predisposition of women, there is, in my estimation, one cause of broken breast to which, I believe, allusion is seldom made. I mean squeezing the infant's breasts soon after birth. I have frequently been asked by nurses “shall I squeeze the baby's breasts when they swell? A nurse who does not hesitate to ask this question, should not be tolerated; for as surely as she thinks it, she will squeeze the child's breasts, let the doctor allow it or not; I know that it has happened, and am morally certain that it will happen again, as long as nurses are represented by the uneducated classes so commonly seen. Nurses are the same all over the world; as a proof see Dr. Hartmann's book on Diseases of Children, where he alludes to the practice of squeezing the child's breasts. Though Dr. Hartmann at once exhibits the primary danger of this operation, the remote and more serious consequences did not become apparent to me until I had some experience of my own. Some old nurses have told me that, some time ago, the practice alluded to was very common; sensible nurses of the better and rarer class nowadays do not adopt it, but among the common kind, attending the less enlightened portion of our population, I am sure that it is as much in vogue as it ever could have been, and, unless a sharp look out is kept, it will be as sure to follow as the administration of “saffron tea to bring out the red gum” (Strophulus).

The object of this despicable meddlesome procedure is ostensibly to reduce the swelling of the infant's breast, observable soon after birth. This swelling may be caused partly by mechanical pressure during parturition, but it seems to coincide more particularly with the development of independent circulation in the child's body, when respiration becomes full and vigorous sanguification takes place. At this period the glandular structures take a new start as it were; a greater influx of blood may be assumed and, at any rate, this process becoming visible in the infantile breasts indicates the future importance of these organs. It is alike in both sexes. In the foetus and up to a certain age in either sex, there is no perceptible difference in the structure of the mammary gland, which may be recognized early in the fetal life, and, according, to Carpenter, may be easily recognized by its redness and high vascularity. I am not acquainted with any description of the progressive development of the mammary gland, exhibiting the degree of resemblance between its fetal and mature condition; though its progress is well observed from the commencement of puberty upwards. At its period of perfection the gland is seen to consist of lobes and lobules, or glands and glandules, connected by lactiferous tubes which intermingle and ramify with each other; terminating in reservoirs and mammillary tubes, composed of a fibrous coat, lined with mucous membrane, which appears to have been traced into the ultimate clusters of follicles composing the glandules; the whole being held together by fibro-cellular tissue.

This is the condition of the gland in its perfection. In examining a premature fetus, born even several months before its full term, we find all the organs of the body already formed, and anatomically definable, eyes, hair, sexual organs and all, even to the minutest detail. Knowing this to be the case, we may safely assume great, if not perfect analogy between the early and mature structure of the mammary gland.

What happens now, if violence is used in emptying an infant's breast of the muco-serous fluid it contains after birth? The fluid is partially pressed out; the extremely delicate rudimentary follicles may be contused or lacerated in their state of distention, and the walls of the tubules and ducts brought together more or less throughout the organ. The healing process next sets in, cementing and gluing together by new cell growth, the lacerated follicles and ducts. But what of that, the child does well, especially if a boy, but if it happens to be a girl, what then? In a certain number of years she will be a mother, vainly trying to nurse her child. The doctor will find nurses, aunts and grandmothers rubbing and oiling away at a sore breast in which “the milk has caked,” and which is very tender and red, with a deep depression where there ought to be a protruding nipple; and notwithstanding the vigorous efforts of the child, nurse or breast-pump, these will never draw it out again.

Such a case may or may not terminate in suppuration. I have seen cases where the activity of the gland would gradually subside without that painful termination, but probably most cases would end so.

I do not intend the inference that all cases of deformed nipples, or inability to nurse are caused by the practice of squeezing the female infant's breasts, but I believe that many of them are. I have suspected it in many, and know it to be a fact in several; in these instances the nipple was drawn in, or rather it was not protruded as it should have been when the breast began to enlarge, previous to the formation of milk, held back, as it were, by the contracted mammillary tubes or cicatrized cellular structure at the base of the nipple. Milk may be abundantly secreted in the sound portion of the organ, but cannot easily be drawn out.

Are there any remedies for such a case? I doubt that such a condition can be cured. But efforts should always be made for the purpose of restoring the normal shape of the nipple, and for this end there is no better instrument than the mouth of some kind person who may be found willing to draw the patient's breasts; and I am bound to say in justice to nurses, that I do not remember one who shrank from this task of pure and disinterested philanthropy. But as far as my experience goes, only partial relief is obtained; both mother and nurse are too often compelled to give up in despair after days or perhaps weeks of patient endurance.

There are, however, many other cases of malformed nipples perhaps by far the most numerous, which do not depend on the causes above described, and which will often readily yield to careful and patient management.

BROKEN BREAST AND SCROFULA WITH A GLANCE AT PSORA. - While speaking of sore nipples, I counted a certain constitutional taint among the predisposing causes of that complaint, and this applies with full force to the topic of inflamed and “broken breast.” It is common to meet with cases in which, after a natural term of gestation and subsequent delivery, the patient's breast becomes hard, painful and is accompanied by marked febrile excitement of some duration, followed by copious suppuration, running the usual course of phlegmonous inflammation. Such a condition is apt to set in mostly two or three weeks after confinement, and is certainly most common during the first three mouths. Some are attacked after every confinement. Sometimes the gland itself is affected, at others probably only the interglandular tissue, or the fascia and skin covering the gland.

But what shall we call this predisposition, how can it be defined, or among which types of morbid conditions can it be classed? Authors in the old school of medicine, including Virchow, mention several pre-eminent types of constitutional predisposition, among which the scrofulous and carcinomatous dyscrasies are, perhaps, the most prominent ones. Hahnemann assumes three grand types from which all conceivable chronic diseases arise.

Without entering into the details of this classification here, I will only state that I cannot accept them as absolute truths, but find in them much that is relatively true and eminently calculated to lead to practical results.

While the classification of dyscrasies, adopted by the prevailing authorities, of the old school e. g. Canstatt, may be considered as a scientific attempt without the least importance as to curative results, Hahnemann's arrangement of chronic diseases, in three grand types is, to say the least, of great practical value, since it has led directly to certain corresponding typical classes of remedies. According to Hahnemann all chronic diseases not dependent on syphilis or sycosis are derived from itch miasm. May this be true or not, the whole question turns on the word psora or itch. We may alter that word as we will, we may use in its stead the entire list of (non-syphilitic) contagious and non-contagious skin diseases, the fact remains indisputable that many of them, including itch, may change from a peripheric to an internal morbid condition; and, as Hahnemann admits, the types may be complicated with each other. On this account the importance attached by the great master to this pathological speculation, is everywhere secondary to the great general rule, always and distinctly repeated by him to select the remedy according to the maxim, similia similibus curentur.

The New Zeitschrift fur Homoeopathische Klinik, Vol. VIII, No. 17, contains a copy of an article bearing Hahnemann's signature, published in one of the popular newspapers of his day, thirty-six years before the publication of the Chronic Diseases, in which article the author clearly sets forth that the true source of itch is the presence of little animals, often observed by himself and others. Sulphur, in the form of ointment or liver of Sulphur are set forth as safe and certain remedies. Dr. Langheinz, of Darmstadt, who discovered this important and lost fragment, naturally draws conclusions in opposition to the psora theory in its connection with The Chronic Diseases, where, curiously enough, the little animal is not alluded to.

The same periodical, Vol. IX, No.2, contains an article by Dr. Roth, of Paris, detailing the discovery of Dr. Rayer, that a certain epizootic disease of sheep and cattle (sang de rate, apoplexie charboneuse de la rate; German, milzbrand,) was dependent entirely on the presence of certain animalcules (Bacterien), invariably discovered with the microscope in the blood of animals having died of that disease. From these discoveries the inference is drawn of the entire futility of the psora theory. (See Vol. IX, No. 12, Feuilleton, where strong arguments are brought forward against the animal nature of these infusoria.)

Since we possess a homoeopathic law and a Materia Medica which has already cured as many diseases as it contains “pure” symptoms, it need not disturb the tranquility of Homoeopathicians what becomes of the psora theory. There is no doubt that the Sarcoptes hominis, and chiefly the female of the species, is the cause of many forms of itch, as many other vegetable or animal parasites are the cause of as many different forms of disease. But why should this animal produce only such a specific form of disease? There is no doubt that this is owing to a specific poison of the animal and not alone to the kind of mechanical irritation produced by the motions of the bristly, lively little parasite. A sting inflicted by a needle is as different from that of insects as their stings vary in effect from each other. It is an easy matter to distinguish the sting of a mosquito, gnat, bee, wasp, bed-bug, etc. By all these, a poison, as specific as that of any known miasm, is imparted to the body, why not by the Sarcoptes? An interesting series of experiments might be instituted in order to determine how much itch is dependent on mechanical irritation; numerous analogies drawn from common experience may, for the present, suffice to show that simple, non-poisonous foreign bodies, however complex in structure, seldom if ever produce sensations resembling the voluptuous itching, smarting or stinging of specific poisons brought in contact with the skin, or introduced beneath it. Of all such poisons, that of the Sarcoptes is in many respects the most tenacious, scarcely healing without curative interference, and often lasting long after the disappearance of all visible traces of the diseases. (See Constatt Pathology and Therapeutics, Vol. IV, p. 1135.)

In short, the contagion is there, whether Hahnemann knew its true nature or not. The fact that suppression of chronic itch, or of any other severe cutaneous disease, is followed by various other disorders is undisputable.

There is no doubt, on the other hand, that many forms of chronic diseases originate from numerous other sources besides suppressed or inherited skin diseases and psora. But these views do not necessarily contradict each other, but it is justly claimed by many authors, among them von Grauvogl, that it serves to enlarge and complete the pathological system, whose grand logical end is to point out classes of remedies, corresponding to classes of diseases. Hahnemann is the first who ever attempted such a gigantic task with success, and pathological science is barren and to no purpose (if cure is the object of medical science), so long as diseases are classified without regard to classes of curative agents, with which they stand in correlation. Homoeopathy and its maxims furnish the only means and method to the end of developing the Materia Medica, parallel with Pathology. The latter science, before the days of Homoeopathy, had gone one way, while Therapeutics and Materia Medica went another, or oftener still came to a dead halt, or, like the great rivers of Australia, ran away from the ocean to dwindle in the sands of the interior desert.

The words scrofula and psora are often confounded in common parlance. But since the former is used to designate a dyscrasy, clearly definable and often well described, it may be permitted, as applicable to the pathological condition to be described.

Scrofula ordinarily denotes a tendency of glandular structures to swell, and the occurrence of deposits of certain morbid (tubercular) matter in their substance, ending in suppuration. But the word has been made to apply to many other conditions. Ulcers of the skin and the vast array of suppurative diseases come within its scope. It may become manifest in the most various modes, from Tuberculosis, with which it is always considered identical, down to Acne. But whenever seen there is the tendency to suppuration, so apt to follow with extreme rapidity in “scrofulous” organizations; while a healthy body will endure an inflammatory process without final suppuration, or even escape inflammation altogether, where it might reasonably be feared. A scrofulous subject will show an extensive inflammation and a huge quantity of pus in a very short time, caused perhaps by slight mechanical injury or a draught of air.

This is the case with a great proportion of women suffering with broken breast. Though we may not have noticed any signs of approaching trouble in our previous acquaintance with such a patient, her first confinement will reveal her constitutional condition. Lactation and suckling may go on without complaint for awhile; but not many days will elapse before the first well known signs of inflammation set in.

The actual condition of the glandular structures and those of the breast in particular, tending to suppuration is very difficult to conceive. The morbid anatomy of such a case must of necessity be practically undemonstrable, though more or less readily inferred from analogy. But one circumstance seems appreciable, that, in a case of broken breast, occurring in a scrofulous patient, the affected organs are not in a state of development, enabling them to withstand the activity of lactation going on within them. [Canstatt defines scrofula and tuberculosis as “a standing still at a low degree of organization.”]

When the secretion of milk fairly begins in a healthy breast a certain degree of turgescence takes place, as a reflex action, in response to a nervous stimulus, resulting in the production of secreting cells in the ultimate subdivisions of the glandules. In a morbidly predisposed gland, however, the nervous centres do not take the hint correctly from the stimulus applied; they actually misinterpret it; the process of healthy turgescence, instead of terminating in relief by the flow of milk, is perverted into an angry inflammation, dragging into its sphere all subordinate structures, such as cell walls and cellular tissue. The process, like an impatient artizan, wears out and destroys its tools before accomplishing the object perfectly, and the product at the termination is pus where it should have been milk.

The views of Prof. Virchow as defined in his Cellular Pathology have some relation of interest to our subject. After discussing (chap. ix) the formation of tubercular matter, a product of inflammation left as a residue in glandular interstices, after the absorption of watery fluid parts, etc., he comes to a second form of reabsorption of pus (p.171), where pus really vanishes without residue; “but here too,” the author continues, “pus is not reabsorbed as such, but undergoes a fatty metamorphosis; each individual cell liberates fatty particles within itself; breaks up and finally nothing remains but fat granules and intercellular fluid. Thus neither cells nor pus remain; their place being taken by a kind of milk, [The Italics are not in the German original composed of water, some albuminous substances and fat, and often found to contain sugar, increasing the analogy with real milk. This pathological milk afterwards undergoes reabsorption, not as pus but as fat, water and salts.”

Further on (chap. xv, on fatty degeneration) Virchow continues: “proceeding to the third series of fatty conditions coinciding with the resolution of elements, we find their proper physiological illustration, already alluded to, in the secretion of milk as well as in that of sebaceous matter of the skin. That these two secretions are analogous is explained by the circumstance that the milk gland is nothing more than an enormously developed and peculiarly formed accumulation of cutaneous glands (sebaceous follicles). In the order of their development both series are parallel; both proceeding from progressive growth of the exterior layers of epidermis.” After describing the nature of sebaceous follicles and the process of the formation of their contents, the author continues, “this process furnishes us with an exact plan of the formation of the milk. It is only necessary to imagine the ducts more elongated and the terminal acini more developed; the process remains essentially the same. The cells thrive and then pass into fatty metamorphosis, break up and at last nothing more substantial is left of them but fat drops. Coinciding more particularly with the common mode or sebaceous secretion is the early period of lactation furnishing the so-called colostrum.”

Now in applying the above to a case of phlegmonous inflammation of the breast, the normal secretion of which bears analogy to pus, the inference is at hand, that the change of milk into pus may actually occur; at all events the abundant secretion of pus from the cellular elements originally destined to become milk is illustrated by Virchow's views, with that difference, that, according to the latter, pus changes into” a kind of milk.“

When such an inflammation attacks a healthy women, caused by exposure or violence, it will often readily get well under the use of cold compresses. Arnica certainly is beneficial, administered internally and externally; likewise Ruta and Calendula. In diffused, pale redness, tenderness on slight pressure, where there is febrile excitement, when the disease is caused by cold air, with stiffness of the joints and back, Bryonia is the right remedy, by the use of which I have seen such symptoms vanish sufficiently often to assure me of its efficacy.

When the disease is attributable to malformed nipples owing to causes above mentioned or any others, the result depends on the constitutional condition of the patient; if she is free from dyscratic taint, the chances are that the ensuing inflammation may subside without abscess, or that the remedies above mentioned may assist much in allaying the storm excited by prevented suckling.

But let inflammation set in where there is constitutional predisposition to this process and easy suppuration, the state of things will be deplorable in the extreme. We may be fortunate enough to bring about a speedy termination of the process by skilful management therapeutically or simple external applications, but it has often appeared to me that treating a patient for an individual case of broken breast, has many features in common with the treatment of a patient suffering from periodical convulsions; the least benefit can be afforded during the attack; more might perhaps be done previously or subsequently by proper homoeopathic remedies; and to arrive at a fair estimate of the powers of remedies in this complaint has been a serious desire in my practice.

The remedies which have been followed by satisfactory results in scrofulous patients, with inflamed and suppurating breasts, were Aconite, Bryonia, Silicea and Sulphur. The indications for Aconite and Bryonia are stated as clearly in Hahnemann's provings as in any subsequent ones. The distinctive features of the two, relating to inflamed breasts, are high and full pulse; heat, with or without thirst; rigors and marked febrile heat, and where the local symptoms are not yet very prominent, though the contrary is by no means an objection. Where a similar condition exists, Aconite has many times reduced it within eight or nine hours, leaving only the local inflammation to follow its course. Bryonia may often be our first choice; or, when the first of the storm is over or less apparent than it is where Aconite would meet the case; when there are many aching pains in the joints inward chills and marked distress on moving; when the breast is tense, pale red or shiny red, and extremely sensitive to the touch, which is not so marked in the first onset, where Aconite may do well. I believe that we have a right to expect a decisive result from a remedy within twenty-four hours in such cases. I can recall instances when, in less time, the diffused inflammation was reduced to half its extent, accompanied by relaxation of the breast, after Bryonia. I am equally confident that several aggravated cases have got well entirely under the use of that remedy. Undeniably the majority of cases, particularly in scrofulous patients, have terminated in suppuration, many without indicating any effect from the remedies.

In scrofulous patients, where the inflammatory process is slow and suppuration tedious, without marked fever or tenderness, Sulphur has been most useful. In one case of suppurating breast and two analogous cases of parotitis, one following scarlet fever and the other from ordinary causes, the abscess distinctly wilted down and got well, without breaking or puncture, where fluctuation was unmistakable, the abscess already “pointing.” Where opportunity is afforded of becoming acquainted with the constitutional habit of a patient, months before her expected confinement, and especially when there is a scrofulous taint to be discerned, Sulphur repeated at long intervals has appeared serviceable, though much experience is yet necessary to establish decided views concerning this procedure.

Silicea is another of the old remedies which has repeatedly satisfied my expectations. It has not stopped or prevented abscess of the breast; but in profuse suppuration, when pus is discharged by the teacupful throughout the day, especially if the matter is inclined to become thin, or profuse and creamy; also in protracted suppuration Silicea has promptly arrested excessive flow of pus often in less than twelve hours, where it had existed for several days or a week previously. Like Sulphur I have habitually used Silicea in the thirtieth dilution.

Far from supposing the list of remedies to end here, I have simply mentioned those that have been of actual service in my hands. In order to avoid the appearance of having made unfounded assertions, it will be necessary to confirm them as soon as time and opportunity will permit.