pression on a tense breast before the abscess is opened, but is not applicable in a flaccid breast. Most simple of all is the compression by suitably arranged napkins and the daily emptying of the cavity of the abscess. If the abscess is in the lower lobe a simple suspensory bandage suffices; if it is higher, the bandage must be applied round the thorax.

If the pus is thin and the granulations flabby it is well to stimulate the healing process by the injection of a solution of nitrate of silver.

An abscess does not render the weaning of the child absolutely necessary; but if an abscess communicates with the lacteal duct it is advisable to wean the child, at least from the diseased breast. The sinuses and lacteal fistula which remain commonly heal only when lactation is entirely stopped.

(c) Galactocele.-It very rarely happens that when the excretory duct is occluded the secretion still continues without an abscess developing. The lacteal duct becomes more and more dilated, and even forms a large cavity, or one of its walls ruptures, and the milk remains in the newly formed abscess-like cavity. Usually these milk-abscesses are small, yet they may acquire an excessive size, as in the case of Scarpa, where the tumour descended to the left flank, and contained ten pounds of milk.

The tumour at first contains pure milk; later on, the serum separates, and the solid constituents are inspissated, or hæmorrhage into the cyst produces a mixture with blood and of a great variety of colours.

The diagnosis may be very difficult. If the wall of the lacteal duct has not ruptured, from the hard consistency and the distinct fluctuation it may be easily mistaken for a cyst, and after rupture into the surrounding tissue for an abscess.

The treatment is not materially altered by the uncertainty in the diagnosis. After puncture alone the contents again accumulate, and inflammation of the walls of the duct must be produced by injections of iodine. If the cyst does not close in this way it must be laid open by an incision, and allowed to close by suppuration.

2. Inflammation of the Breast

The phlegmonous inflammation of the connective tissue of the breast may be limited to circumscribed spots of the areola. The inflammation then usually proceeds from the fissures of the nipple or from the glands of the areola to the connective tissue in the immediate vicinity. Around the nipple small furunculous abscesses form.

Besides the implication of the connective tissue, which regularly occurs in parenchymatous mastitis, there are also during the puerperal state inflammations of the connective tissue, with a tendency to suppuration, most frequently due to an injury. More frequently this is phlegmonous erysipelas in consequence of septic infection from slight excoriations of the nipple. They are either limited to the breast, and may then terminate in an abscess, or they may end in mortification, and death may follow in consequence of an infection of the whole organism. When abscesses form, the pus must be

evacuated as early as possible, and this is done by multiple, large, and deep incisions.

In rare cases the submammary connective tissue between the gland and the thorax inflames in the puerperal state. This is the consequence of a blow or of the implication of the connective tissue in the inflammation of the deeper glandular lobes.

The breast is swollen and feels as if it rested on a water-cushion. The base of the breast becomes oedematous. Unless incisions are early made, it may go on to tedious and dangerous burrowing of the pus.

3. Diseases of the Nipples.-Chaps

The nipples, covered by a delicate epidermis, are in women who nurse easily exposed to disease. Various conditions predispose to it. By nursing the child or the flow of the milk, the nipple is softened, and the epidermis is raised in the shape of vesicles, which form scabs, under which the epidermis is replaced. Also at the tip and the base of the nipple folds are found, where the epidermis is still more tender and more closely adherent. If the folds have been bridged over by scabs formed of discharged colostrum and dirt, and if the scabs are torn asunder by sucking, the folds are opened up in their entire length, and chaps result. In women in whom those folds are little developed, so that their nipples have quite a smooth appearance, chaps are not easily formed. Others, on the contrary, have deeply fissured nipples, and on separating the small papillæ, even before the child is applied, red, somewhat moist and painful spots are seen. Chaps in these cases are seldom absent when the child begins to suck. Nipples also which freely project, so that the child can grasp them without trouble, are much less disposed to the formation of chaps than those which the child must continually drag upon in order to retain its hold on them.

These chaps are a great source of annoyance to nursing women. Nursing the child causes very severe pain, whilst the simple excoriations with small scabs and ecchymoses are much less sensitive, but may, of course, lead to actual chaps. The chaps also may cause intense fever, though this is absent in most cases. The occurrence or absence of the fever depends partly upon the size of the chaps, partly also upon their depth, and the sensitiveness and irritability of the individual. In some cases the fever may rise to above 40° C., but with the cessation of the irritation it rapidly abates.

If the chaps are neglected they become deeper and more sensitive. The women are in a continual state of anxiety, and greatly dread each fresh application of the child to the breast. There is want of sleep, the appetite is diminished, and fever consumes their strength. In suckling the child the nipple is involuntarily drawn back for fear of the pain, so that the chaps are still more torn open, and, at last, when the pains become too severe and the secretion of the milk ceases, the child has to be weaned. Under certain circumstances the chaps may extend so much in depth that the nipple is almost entirely separated from the breast, and the connection is maintained only by

the lacteal ducts.

In other cases the resulting scabs occlude some of the larger

lacteal ducts, and in the corresponding glandular lobes the secretion is retained, which is followed by a parenchymatous inflammation, often terminating in suppuration.

Prophylactic measures are required even during pregnancy. Care must be taken that the nipples sufficiently project and that the epidermis is somewhat hardened. The former is obtained by frequent traction with the fingers or with sucking glasses; the latter by scrupulous cleanliness of the nipples and frequent washing with cold water, spirits of wine, or if the skin is very tender with weak solutions of tannic acid.

If the woman begins to suckle with prominent, healthy nipples, chaps do not easily form. If, nevertheless, the nipples remain small, so that the child can only grasp them with difficulty, the milk pump must be used before the child is put to the breast, and the child will then find the whole nipple full of milk.

When there are chaps it is best to cauterize them immediately with the solid nitrate of silver, so that the whole base of the chap is covered over by an eschar. The child, of course, cannot be put to the breast until the surface beneath the scab is healed, else the scab would be torn off and the chap again irritated.

If the child cannot be weaned for so long a time, the base of the chap must be frequently cleansed, or the base is cleared by cauterization, and a few threads of charpie soaked in a solution of tannic acid (gram j in 30-50 grammes of water) are placed into the chap. If this is kept clean, or treated as recommended, it rapidly fills from below upwards and heals.

G. MENTAL DISEASES OF PUERPERAL WOMEN

The mental diseases of puerperal women have by no means particular and distinctive characters. It suffices to say that gestation, labour, and the puerperal state are very powerful etiological factors in certain mental disturbances.

Daily observation shows what a great rôle the sexual apparatus plays in the psychical life of women. Witness hysteria, and its intimate connection with diseases of the genital organs. Already in the physiology of parturition attention has been drawn to its influence upon the mental state of women. Sometimes seriously disposed women become excessively merry, whilst, on the contrary, gay young women easily assume a serious, even shy and melancholy disposition. But in rare instances this latter goes so far as to develop into a real disease. Most frequently the gloomy frame of mind. passes off with the puerperal state.

The influence of pregnancy upon the cerebral organs may partly be explained on physiological principles. The congestions to the head which accompany pregnancy may just as well give rise to nutritive disturbances of the brain as they do to the formation of osteophytes in its bony envelope. And not only is the great quantity, but also the abnormal quality, of the blood concerned in those nutritive disturbances. The not infrequent acute hæmorrhages during pregnancy and parturition are undoubtedly in some causal connection with the psychical state, which arises from the puerperal condition.

The fact also must be borne in mind, that often pregnant and parturient women are extremely sensitive to psychical affections, and this is especially the case with those illegitimately pregnant. In a great number of the mental diseases of women, the origin of the disease can easily be deduced from the puerperal state. It is, of course, easily intelligible that the predisposing causes which are to be taken into consideration in other causes of mental diseases are of great moment as regards the origin of those diseases after child-bed.

Corresponding to the state of mind displayed during pregnancy or parturition, the psychical disturbances are either those of depression or of exaltation.

The slight forms of melancholy usually originate during pregnancy, and are continued into child-bed, where they may develop into the graver forms of melancholy.

The attacks of mania most frequently occur during parturition. At the moment when the head passes the vulva, and when the suffering reaches the highest degree, acute mania is not rarely seen. Otherwise patient and intelligent women suddenly cry out loudly, wildly stare around them, and menace and strike those who are near them. In the great majority of instances this state disappears immediately after the expulsion of the child, but exceptionally it may also continue after delivery.

Attacks of mania accompanying puerperal diseases are also symptoms of cerebral irritation.

The prognosis of mental diseases originating during the puerperal state is, on the whole, relatively favorable.

As regards the treatment, it is best to watch the patients carefully until their conditions will allow them to be removed to an asylum. Melancholic lying-in women must never be left alone on account of the possibility of their committing suicide.

APPENDIX.-SUDDEN DEATH IN THE PUERPERAL STATE

We shall have to consider those sad cases where death quite suddenly and unexpectedly occurs in lying-in women who have been perfectly well or only slightly indisposed.

The more frequent causes of sudden death, such as very profuse hæmorrhage, the very acute form of septic infection, dangerous apoplexies, or rupture of the heart in consequence of acute myocarditis, of which Spiegelberg has observed a very interesting case, have already been mentioned in the previous chapters. It only remains to speak of two not very rare causes of sudden death during or after delivery, namely, embolism of the pulmonary artery and entrance of air into the uterine veins.

1. Embolism of the Pulmonary Artery

As already stated above, embolism occurs most frequently in the course of puerperal fever. Under the influence of the septic infection the thrombi which have formed in the veins, either as a physiological process or in consequence of an extension of the inflammation of the connective tissue around the veins, become

disintegrated. However, in the great majority of instances only the smaller branches of the pulmonary artery are the seat of those embolisms, because the thrombi usually break down into very small fragments.

Embolism is happily very rare apart from septic infection. Only, if a physiological thrombosis continues into a larger vein, a piece of the thrombus may be washed away by the current of the blood. Such a large thrombus may then pass through the right heart into the pulmonary artery and obstruct it or, at least, one of its larger branches. Death occurs then either suddenly or in a few days with symptoms of increasing dyspnoea, cyanosis, and a low temperature. The carefully observed case of Rutter is very instructive in this respect. After the observations of Playfair and others, it is not improbable that recovery may take place under favorable conditions.

2. Entrance of Air into the Uterine Veins

Experience has taught us that air entering into the veins may give rise to very alarming symptoms or even cause sudden death. This has been frequently seen in operations about the neck, when the veins which are situated between the fascia, and therefore unable to collapse, have been wounded.

But air may also enter the uterine veins during or shortly after delivery, and may cause sudden collapse or even death. Now, many facts go to prove that in parturient and lying-in women air may and not infrequently does enter the vagina and uterus, not only in operative procedures, but also in simple examinations. But it is doubtful whether the air spontaneously enters the veins, or whether it is pressed into them by the contractions of the uterus, whilst the os uteri is displaced. The cases of Olshausen and Litzmann unmistakably show that such an entrance can take place, when by means of an injection apparatus air is forced with the water into the uterus under a certain pressure.

Every precaution should, therefore, be taken in making injections into the uterus of a parturient and lying-in woman. The piston must accurately fit into the syringe, and every bubble of air must be previously removed from it."

Literature.-Deneux, Mém. sur les Tumeurs sang. de la vulve et du vagin. Paris, 1830.-Blot, Des Tumeurs sang., &c. Paris, 1853.-Chiari, Braun and Spaeth, Kl. d. Geb., p. 219.-Hecker, Kl. d. Geb., B I, p. 158.-v. Franque, Wiener Med. Presse, 1865, Nos. 47, 48.-Hugenberger, Petersb. Med. Z., 1865, H. 11, p. 257.-Winkel, Pathol. d. Wochenb., 2 Aufl., p. 129.-Kiwisch, Krankh. d.Wöchnerinnen, II, p. 160, 167, and 170.-Scanzoni, Kiwisch's Klin. Vortr., B. III. Prag, 1855, p. 108.-Veit, Frauenkrankh., p. 612.-Winkel, Path. u.Ther. des Wochenbettes, p. 353.-Winkel, M. f. G., B. 22, p. 348, and Path. d. Wochenb., 2 Aufl., p. 405.-Schroeder, M. f. G., B. 27, p. 114, and Schw., Geb. u. W., p. 194.-Wolf, M. f. G., B. 27, p. 241.— Schramm, Scanzoni's Beiträge, B. V, H. 1, p. 1.-Veit, Frauenkrankh., p. 606.— Virchow, Geschwülste I, p. 283.-Veit. Frauenkrankh., 2 Aufl, p. 610.-Winkel, M. f. G., B. 22, p. 345, and Berl. klin. Woch., 1864, No. 2.-Scharlau, Berl. klin. Woch., 1864, Nos. 19 and 20.-Berndt, Krankh. d. Wöchn. Erlangen, 1846.— Leubuscher, Verh. d. Ges. f. Geb. in Berlin., III, p. 94.-Ideler, Charitéannalen, 1852, I. Scanzoni, Kl. Vorträge von Kiwisch., B. III, p. 520.- Veit, Frauenkrankh., 2 Aufl., p. 705.-Tuke, Edinburgh Medical Journal, January, 1867 (s. Virchow-Hirsch'scher Jahresb. über 1867, B. II, Abth. 3, p. 605.-Winkel, Path. u. Ther. d. Wochenbettes, 2 Aufl., p. 449.-Weber, Allg. Med. Centralzeitung,