cleanliness. Each inflamed and suppurating gland should be opened, curetted, and its interior touched with strong bichlorid solution.

Exaggerated pigmentation of the areola often persists after pregnancy; it fades away in the course of lactation or after the child has been weaned.

Congestion and engorgement of the mammæ occur in almost every case on the third day, when lactation is instituted.

Treatment.-Excessive congestion may be avoided by administering a saline purge on the evening of the second day. The breasts must be thoroughly evacuated at regular intervals by the child's mouth, reinforced, if necessary, by massage and a breastpump. Hot fomentations may give great comfort; but if the congestion and pain persist, lead-water and alcohol is the best

application. A mammary binder is almost always a necessary part of the treatment. The pressure and support which it affords contribute more than any other single item in the management of these cases to prevent excessive congestion and engorgement.

From the investigations of Honigmann and Ringel,2 it appears that human milk contains normally the staphylococcus pyogenes albus, as well as the staphylococcus aureus. These micro-organisms wander in along the milk-ducts from the skin. They produce, usually, no ill results, unless the vitality of the epithelial cells is reduced by engorgement of the gland with milk

1 F. Honigmann, " Bakteriologische Untersuchungen ueber Frauenmilch," Inaug. Diss., Breslau, 1893.

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2 Ringel, Ueber den Keimgehalt der Frauenmilch," "München. med. Wochenschr.," 1894, No. 27.

and blood, as in the "caked breast." They may then take an active part in the development of a mammary abscess, by attacking the epithelial cells of the milk-ducts, destroying them, and invading the surrounding connective tissue.

Sore Nipples.-Excoriations and fissures of the nipples are due to the maceration and irritation to which they are subjected by the child's gums and mouth. Mammary abscess not infrequently results from the entrance of streptococci or of other infectious bacteria through these fissures.

Prophylactic Treatment.-During the latter months of preg nancy the nipple should be washed twice a day, and should then be touched with a piece of clean absorbent cotton, saturated with a mixture of glycerol of tannin and water, equal parts. Alcoholic astringents should be avoided. It is necessary, of course, to keep the nipple clean during lactation by bathing it with boric acid solution (gr. x to f3j), and to keep the skin in a healthy

condition by frequent applications of sweet-oil, until the nipple becomes accustomed to its functions.

Curative Treatment.-The nipple should be carefully cleansed after each nursing, and one of the following remedies should be applied to it: An ointment composed of 3ij each of bismuth subnit. and castor oil; tinct. benzoin comp., applied directly to the fissure. Iodoform, gr. x, to ung. zinci oxidi, 3ss; ichthyol, 3j; lanolin, glycerin, each 3iss; olive oil, 3iiss. The fissure may be touched with a solution of nitrate of silver (gr. x to the ounce) or with the solid stick. A nipple-shield is almost always necessary. It must be perfectly clean, and should be kept immersed in cool water while not in use. In cases of supersensitive nipples, without abrasions or cracks, or if the latter are slight in degree, extract of witch-hazel is an excellent remedy. Occasionally the nipples are so exquisitely sensitive that the pressure of a nightgown or of the bed-clothes is unendurable, although there is

no fissure, crack, abrasion, or inflammation. In such cases nervesedatives internally and cocain as a local application are necessary. Usually, the child must be weaned.

Inflammations of the Breasts-Mastitis.-There may be an inflammation of the subcutaneous connective tissue, of the mammary gland, of the deeper interstitial tissue, or of the parenchyma. A septic inflammation is rarely confined strictly to one of these localities. There is usually

involvement of all the tissues in the gland.

Causes.-The first two classes, superficial and interstitial mastitis, are due to sepsis, the result of direct inoculation. The sources of infection are unclean fingers, contaminated water, soiled rags to dry the nipple, dirty cloths laid over the breasts, and stomatitis in the infant. Parenchymatous inflammation need not always be ascribed to this cause. Overactivity of the gland, engorgement with blood, and distention with milk (the so-called "caked breast") may be primarily responsible for the infectious inflammation by weakening the resisting power of the cells against microbic invasion.

Fig. 511. Puerperal mastitis forming abscess: a, Group of acini melted to pus (Billroth).

Treatment. If the inflammation is parenchymatous and is due to oversecretion, the breast must be emptied with a pump or by massage (see Fig. 507), and must be supported by a binder. If the inflammation is confined to the connective tissue and suppuration is threatened, lead-water and alcohol should be applied with a mammary binder. Suckling had best be intermitted if the inflammation continues and an abscess is threatened, as the irritation of nursing may increase the mammary congestion and the milk is apt to disagree with the child. It has rarely given rise

to septic infection of the child's intestines by its contained microorganisms.

Mammary Abscess.-The pus may be located superficially, in the gland-substance, or in the submammary connective tissue, as postmammary abscess.

The symptoms of suppuration are uncertain. The reddened. skin, the swelling and sensitiveness of the breast, and the fever may be due simply to intense congestion. Fluctuation is rarely detected until late, and should not be awaited. A dusky-red hue of the skin, and edema, with fever, are the most valuable signs of suppuration, and should indicate an immediate incision or incisions.

Treatment.-A mammary abscess must be incised as soon as the physician is satisfied that there may be pus within the breast. It is much better to make an unnecessary incision than to allow

the pus to burrow through the gland until the operation for the woman's relief becomes quite formidable. If the abscess is opened early, one incision commonly suffices. If the case is neglected, every pocket of pus must be opened and every sinus must be drained to secure a prompt and permanent cure. I have made as many as eighteen incisions in the two breasts, and have had half that number of drainage-tubes through the glands in a woman who had been ill for six weeks or more with mammary abscesses, in spite of a few ineffective and insufficient incisions in the breasts, made from time to time by her medical attendant. In incising a mammary abscess, the incisions, so far as possible, should radiate from the nipple, so that they run parallel with the lacteal ducts. Otherwise, a duct may be cut across and a lacteal fistula may result. The incision should, if possible, avoid the area of pigmentation, or should be confined wholly within it, as the pigmentation follows the cut, disfiguring the breast (see Fig. 508). The abscess-cavities should be compressed, after being opened, by a firm mammary binder, and they should be irrigated with sterile water daily.

Fig. 512.-Pigment of the areola following incisions (Richardson).

In the case of a postmammary abscess, the whole breast is lifted off the chest, and there are no signs of suppuration within the gland itself. The systemic symptoms of this kind of mammary abscess are usually severe.

Treatment. The incision should be made beyond the periphery of the gland at the most dependent part as the woman lies on her back, and a counteropening must be made upon the opposite side. A drainage-tube is passed under the gland by a dressing-forceps, and the cavity is irrigated daily.

A galactocele is a milk-tumor due to occlusion of one of the lactiferous ducts. It is usually of no pathological importance, unless it should, as rarely happens, reach a large size, when it must be tapped and drained.

Other mammary tumors, especially adenomata, may take on a very rapid growth in pregnancy, and may become so engorged and painful when lactation begins that their removal is necessary. In one of my cases an adenoma grew during pregnancy from the size of a walnut to that of a cocoanut, and I was obliged to excise it on the third day of the puerperium.

Relaxation of the Pelvic Joints.-The pelvic joints, after labor, may be the seat of inflammation, accompanied by serous exudation, and ending possibly in suppuration. In the case of the symphysis pubis, the abscess can easily be opened and drained. The prognosis, therefore, is good. In the other pelvic joints suppuration is commonly fatal. The pelvic joints may be ruptured by violence during labor. This accident is considered in connection with the forceps operation and injuries to the woman in labor. Finally, there may be, to a marked degree, relaxation of the pelvic joints, much exaggerated beyond that seen in almost every pregnant woman, and persisting for varying periods after delivery.

The etiology is obscure. Abnormal motion in the pelvic bones has been seen in justomajor pelves. It has been noted after abortion. It may be traced to a large, hard fetal head which had stretched the joints. It occurs in justominor pelves rather frequently. It has been ascribed to obesity, to a cachectic condition, to sudden and powerful exertion in the latter months of pregnancy, to an unusually great circumference of the pregnant uterus, and to previous disease or abnormality of the joint. 2

The diagnosis is easy. There is difficult locomotion, unusual mobility in the joints, especially the symphysis pubis, and localized pain.

The treatment should consist in the application of a firm binder about the hips. Tonic remedies are often required. In the course of a few weeks the joints usually become firm. Occasionally, the relaxation persists for months.

1 Winckel," Geburtshülfe," p. 873.

2 Schauta, in Müller's "Handbuch,” vol. ii.