|
AN INTRODUCTORY LETTER TO A FRIEND. [ pp. vii - ix ]
DEAR SIR:
I SEND you a new Medical book, which I beg you to
accept as a testimonial of my respect and affection. I have not dedicated
it to you, because it belongs to the Gentlemen to whom I addressed the
Letters of which the volume consists. I shall be obliged to you if you
will look at it and tell me whether you think I have committed an
unpardonable breach of the forms of our Science, in writing with such a
freedom and abandon as you shall here find; for I might say with Juvenal:
" Quicquid agunt homines ; votum, timor, ira voluptas,
Gaudia, discursus, nostri est farrago libelli."
Dr. Forbes, in his farewell article, in the British and
Foreign Medical Review, tells us it is a lamentable truth that the eminent
practitioners of England neither read nor buy medical books; and I fear a
chief reason of it is to be found in the dulness and jargon which
characterize so many medical writings. I am sure that, exclusive of such
as treat of the Physiology of Man, many of them are very tiresome and
disgusting, for the Doctors seem not to have heeded the lines of Horace,
who says:
" Omne tulit punctum qui miscuit utile dulci,
Lectorem delectando pariterque monendo."
According to my poor ability, I have endeavored in
these Letters, while telling the truth about our Science and Art, to avoid
the dulness; and, in doing so, I have ever thought the honestest way for a
man to speak is to speak what he thinks, in his own tone and manner, and
not to come before the public under a false disguise. The young gentlemen
who composed my Class were accustomed, all winter, to hear me say just
whatever the occasion prompted me to say to them, without any reservation
of mine, from distrust of them ; for I went into the Lecture room with my
heart in my hand open before them, and it is in the same fashion that I
have sent them these Letters. Indeed, when on the spur of an occasion I
promised to write for them, I engaged to adopt the most familiar style,
saying, " I will write in the same language as I should address to any
one of you, whom I might be instructing, in my library here at home."
You will see that I have kept my promise.
Whether such a mode of writing might prove agreeable to
the brethren, so as to meet their approbation, remained to be seen. If I
should fail in this attempt, I may still hope that some one else will
invent a new and happier method than mine to get rid of our medical
dulness, and our time-honored clergyableness.
To judge of the medical student of the present day, by
comparing my own student-life with his, I cannot but think he must daily
find the books, as tedious and uninteresting as they used to be when you
and I were young men like him.
As to the doctrine and the precept of these Letters, I
might well suppose I have a right, at this stage of my life, to be heard
upon them--and having felt it an occasion of self-reproach that I could
never find time, in the winter curriculum, to fulfil my duties as Lecturer
on Diseases of Women and Children; I have taken occasion by speaking to my
Class through the press to supply the deficiency. In doing so, I could not
but stand before the public.
Flaccus says:
" Scribendi recte, sapere est et principium et fons."
You will be able to judge whether I have said that
which is naught as to the diseases treated of herein. Certainly, I have
had much opportunity to see the things spoken of, and if the book turns
out, useless or disagreeable, mine is the fault. You, who have seen so
much, may well become my competent and dispassionate judge.
Let me tell you, though, my dear Hodge, that the whole
of these 698 pages have been begun and finished since the month of May
last. They, therefore, have no claim to the nonum prematur in annum
merit; and I wish you to understand that I have been obliged to do the
whole of the work in addition to my, diurno-nocturnal task of visiting the
sick. I cannot, under these circumstances, expect for it the same
consideration as might be due to essays carefully revised and finished;
and I have a just right to make this apology.
But, shall people, who desire to make a contribution to
the art that has absorbed their whole existence, refrain from doing so
from a fear of offending in the matter of their manner? Would that be
Americanlike? And, shall everybody go out of the world making no sign?
Beaufort was asked but to hold up his band, but "he died, and made no
sign."
I wish you would make a sign for us; we all wish so.
I have made this apology to, you, because I look upon
you as a chief representative of Medicine, on this topic, in the United
States: and, as I desired to say a few words to the Brethren, in general,
in addition to all I have said in these Letters to my Students, I trust
that in saying these things to you, in whom they have confidence, I am,
towards them, absolved as to apologies.
As to my personal feelings towards you--did we not sit
on the same benches at the lectures?--and have we not interchangeably
assisted us with counsel and with dexterity, in, our vocation these thirty
years?--What more!
I pray God to prosper you long; and to allow the City,
and the Country, to enjoy, for many years, the advantages of your skill,
the honor of your well-earned reputation, and the benefit of your public
instruction, as well as your private example as a minister of your
philanthropic calling.
Farewell, dear doctor, and believe me very faithfully
Your affectionate friend,
CHARLES D. MEIGS.
November, 1847.
To Hugh L. Hodge, M. D.,
Professor of Midwifery, and Diseases of
Women and Children, in the University of Pennsylvania.
Letter XLV. [ Concluding letter, pp. 681 - 698 ]
THE BREAST. MAMMARY ABSCESS.
GENTLEMEN: I found her lying in bed, and looking dull
and dispirited when I entered the apartment; whereas, I had parted from
her two days before in excellent spirits, proposing to get up on the
morrow; for by that time, her ninth day, the dies nondince would be
complete. The child was in health; she had had an excellent labor; the
flow of milk was abundant; and not the slightest untoward event had
occurred up to the end of the eighth day.
" I am sorry to find you have been obliged to send
for me, my dear Mrs. ---- . I left you so well the day before yesterday
that, being much occupied, I thought I might lay aside my daily habit of
coming to make you a salaam in the morning; you know that I have had
nothing else to do here since the birth of the infant. You were cheerful
and happy when I saw you last; but now you look downcast and apparently
sick. What can be the matter with you?"
" I have been quite sick, doctor, since yesterday
afternoon."
" What! quite sick, and I not notified of it? Did
you not say, did not this nurse say, did not Mr. B---- say that if, at any
time in the whole course of the month, you should be seized with any
symptom whatever, great or small, I should immediately receive a note,
informing me of it? Here now, you've been sick almost twenty hours before
I am made aware of it. Was this just to me? Was it just to yourself and
your friends? However, I suppose it will always be so with everybody,
since I have found it so with everybody for forty-five years !"
" But the doctor will please to observe that we
did not like to trouble him. It was thought that the indisposition might
readily pass away ; and, indeed, I do feel a little better now than I have
done in the night, or the early part of the morning."
" But what has been the matter with you? What have
you complained of since yesterday afternoon ?"
" I was taken with a chill, sir, at two o'clock,
and I could not get warm for near two hours. This was accompanied and
followed with pain in the head, in the back of the neck, and in the limbs,
that I could hardly endure, after which I became so warm that I was
obliged to throw off some of the coverings."
" Have you any pain in the stomach or bowels?"
" No, sir, not the least."
" Can you draw up and extend the lower extremities
without pain ? Try it; does it hurt you ?"
" No, sir."
" Cough--I wish to know whether, if you cough, it
will give you any pain in the lower part of the bowels. There! that will
do. Does that hurt you?"
" No, sir, it does not."
" Make a great aspiration of air for me. Breathe
hard. Any pain ?"
" Not the least, sir."
" Which of the breasts hurts you ?--the right or
the left one?"
" My breast doesn't hurt me, doctor."
" Yes, it does."
" No, doctor !"
" But, I am sure that it does; and that the cause
of your chill, and of the heat that you have had all night, and that you
still have--for your pulse is quick--is seated in one or more of the
branches of the milk tubes. Will you let me touch the breast?"
" Yes, sir."
" There, now, it hurts you at this point, does it
not ?"
" Ouch ! oh, yes, sir, very much indeed ! Why, I
did not know that I had anything the matter with the breast!"
" But I did, you see."
" Yes, I see that you did. It is very strange that
you should know that I had a pain, when I myself didn't know that I had
it."
" No, it is not at all strange ; it is very easy to
know that ; because it is very easy to perceive in the rate of your pulse,
your breathing, your heart; in the tint of your complexion; in your
physiognomical expression; in your gesture and attitude; in the absence of
pain in the abdomen; in the state of your intellect, evinced by your
answers to my questions, that nothing else could be the matter with you.
In fact, as soon as you said, ‘ I had a chill yesterday afternoon,’ I
knew that you had an attack of what the ladies and nurses call the weed.
You have got a milk-fever, my dear."
This conversation happened yesterday morning, Nov.
20th, 1847. To-day the patient is very well again, for the weed has
disappeared ; that is to say, the milk which had accumulated in excessive
quantities in the lactiferous ducts of the mammary gland, or rather in
certain of them, has been carefully drawn out; and the tension, pressure,
irritation, intension, affluxion, heat, sensibility, redness, and
swelling, all disappeared upon its evacuation.
I have been practising my art now for a great many
years, and I must have seen some hundreds of persons lying sick as this
lady was; some of them with intense fever, cracking headache, intolerable
pain of the nucha, back, and limbs; not unfrequently with nausea and
vomiting; and all this mixed up with distressing flying rigors--to whom I
have said at once, " You have got a lump in your breast;" to
which it has often been replied: " No, I have not."
" Yes, you have."
" No, indeed I have not."
" Indeed you have." Whereupon the nurse
rejoins: " Oh no! there is not any at all, for I examined the breast
very carefully but just now."
" Let me examine it. There, now, does that hurt
you ?"
" No, not at all."
" Does not that ?"
" Oh I dreadfully, dreadfully indeed !"
" I, told you so. It could not be otherwise. How
should it be that I should not understand my business ? I could tell you
had the weed in your breast, if you were in the moon, and I were looking
at you with a spy-glass."
If you are going to practise midwifery, my young
friends, you will have to submit to the aid of what are called nurses; and
suppose you should meet, during your career, with a thousand different
ones, you will not find more than two or three of them that ever saw a
gathered breast. A man would as soon acknowledge that he had stolen a
sheep as a nurse confess, in general, that such an accident had ever
befallen one of her patients. I saw a little darling of a woman here,
about two months ago, more patient than St. Anthony--who had been about
two weeks confined. I had not seen her for four or five days.
Upon receiving a summons, I repaired to her house, and
found her complaining of pain on giving suck to her child;--pain in the
nipple, extending back over the breast, towards its upper and exterior
circumference. I took the breast between my thumb and four fingers so as
to compress the gland in the direction of its latitude or breadth, and found that
gentle pressure gave her very severe pain. Upon touching it
perpendicularly, I discovered a mass of solidified texture, about two
inches and a half in width, by three and a half in length; and, when I
learned that she had had uneasiness in the breast for four or five days, I
said, to the nurse:
" Did I not charge you to inform me if anything
should be the matter with my patient ? telling you to watch her in my
absence, in order that I might have the earliest intimation of any
accident or disorder that might affect her ? Your disobedience has brought
her in danger of a mammary abscess, which may make her ill for three, or
even for six weeks, during which she will experience much pain and
constitutional irritation. You have done very wrong; you have failed
entirely in your duty to this person, who employed you to take care of
her;--you have not taken care of her. I am afraid that she'll have
a gathered breast, notwithstanding everything I can now do to prevent
it."
" Not she, doctor !" replied the nurse,
" not she, indeed ! I have nursed for twenty years, and I have never
had a gathered breast yet, in anybody that I took care of."
" Very well, Mrs. Nurse; you are about to extend
the area of your experience in this very case ; for I think it is very
likely that you will have two; and I wash my, hands of them; for the blame
is yours, and nobody else's. The right breast is gone so far that I have
no hope of curing it, short of a suppuration. The left one is inflamed,
and the fever that your patient is going to have will cause it also to
suppurate, or I am very much mistaken.
This poor lady had two of the most detestable mammary
abscesses that I have seen for the last four or five years.
Now, I have related this story to you for this purpose,
namely, as an introduction to the precept, watch your patient yourself;
for you cannot get anybody, for love or for money, to do your work as it
ought to be done. You may lay down the most definite, clear, precise
directions as to the management of the breast, and you will be sure to be
disobeyed. If the breast will take care of itself, and not get into
disorder, it is well ; but, it is very apt indeed not to take care of
itself, and to subject you to the mortification of an attendance upon a
mammary abscess--always the source of displeasure, disappointment, and
irritation in the family and, to a certain extent, of blame to the
physician.
It touches the nurse in a point of honor to suppose
that her patient could have a gathered breast, because she considers that
her official function consists in taking care of the breast ! and you
might as well tell a physician that be does not understand the Harveian
circulation, as to express any doubt as to the competency of the monthly
nurse to the entire charge of all the circumstances connected with
lactation. I should in vain endeavor--devoting many pages of this letter
to the purpose--to express the thousandth part of the vexations and
mortifications that I have experienced for more than thirty years, from
the ignorance, carelessness, and presumption of those in whom I have been
obliged to put my trust. There are happily some nurses one can trust; but
their name is not legion.
But, I began this letter, designing to speak of the
management of the female breast; let us proceed, therefore, to inquire
what the breast is, its condition in gestation, and in the lying-in state;
and what are the cares that it demands at the hands of the medical
attendant ; and the first thing you have to do in the matter, if you will
be an accoucheur, is to purchase or borrow a copy of Sir Astley Cooper's Treatise
on the Female Breast, which, though it costs about twenty dollars, is
worth a thousand to a man who is to be engaged in this line of practice.
That book will show you that beneath the skin on the front of the chest
there lies--one on each side--a fascia, which sends up fibrous and
cellular digitations to attach to the inner surface of the derm. Between
these frequent digitations exist many adipose cells, that often are found
to contain great quantities of fat, so that, between the external surface
of the fascia and the internal surface of the derm, is a chosen' seat for
the deposit of the adeps that gives to the breast its beautiful
hemispherical form, its smoothness and softness. Within this fascia, of
which I just now spoke, are to be found fifteen, and in some instances as
many as twenty-one efferent ducts of the granules of the milk gland, or
mammary gland. Each of these ducts, called milk-vessels, passes out of the
gland through the skin at the extremity of the nipple. The nipple is, in
fact, a fasciculus of milk tubes, or galactophorous tubes which are
gathered up into a bundle, and protected amidst a number of bloodvessels,
some cellular tela, nerve fibrils and absorbents, within a very delicate
derm and a cuticle that should rather be called an epithelium. There is
also a good supply of apparatus of sebaceous secretion, by means of which
the delicate surface of the nipple is kept in a soft and unctuous state.
Each one of the milk tubes contained within the fascia
of the gland runs right and left, or obliquely or perpendicularly upwards,
or downwards as it divides into numerous branches, becoming finer as they
go inwards from the nipple, and successively dividing, until each of the
minute tubuli terminates in a spherical hollow granule, big as a white
mustard seed, from the inner surface of which the milk is secreted ; for
that is the secreting surface of the milk. Fifty, one hundred, or any
given number of these granules are appropriated to the supply of a
quantity of milk sufficient to fill up and distend its own galactophorous
tube, whose issue is found upon the extremity of the nipple.
If you had a syringe filled with delicate size colored
with vermilion; and if you should introduce the point of the syringe into
one of the milk pores upon the end of the nipple, you might inject the
milk tube, and distend it so much as to make it swell out to the-size of a
large swan quill, or, in some instances, to the size of your little
finger. If the material of the injection should run inwards into every
branch of the galactophorous tube, so as to fill each granule at the
extremity of its branch, you will make a beautiful injection of that part
of the lactiferous apparatus. If you should afterwards fill the syringe
with other colors, green, black, blue, yellow, orange, violet, indigo, or
any of them, you might inject, in succession, each of the fifteen or
twentyone porules at the end of the nipple, with a different colored
mixture, and thus fill up the breast completely with various colored
injections; each of which would run off to the branches of its own
particular galactophorous tube, and nowhere else; so that you might say,
as in boxing the compass, this one runs north, this one north by east,
northeast, southwest, south and by east, northwest, west, and so on, until
you have indicated the direction of each tube separate and distinct. Such
is the anatomy of the breast. It is explained by Sir Astley Cooper in his
delightful. work on that subject.
Now, these galactophorous tubes are supplied with the
force for secreting an immense. quantity of milk, consisting of a mixture
of water, albumen in solution, casein, and oil which you call cream. I
have seen a woman, using a common breast tube, draw out two large
tumblerfuls from one breast, at one sitting ; not that she had two large
tumblerfuls in the breast when she began to draw it, but that she began to
form, and continued to pour out this peculiar compound which we call milk,
until the power of the gland to produce it being exhausted, it at length
gave up the last drops ; demanding rest for half an hour or an hour, until recovering its secretory power; it was ready to
give up as much more.
A good cow has an udder, which, if you could cut it
off, you could readily put it into a very small pail ; yet this same cow
is capable of giving sixteen quarts at a drawing, which may serve to show
you the rapidity with which these extraordinary organs are capable of
pouring out the material that serves for the nutrition of the young.
This morning, September 6th, 1847, at 10 o'clock, Mrs.
C. A. F.'s nurse showed me a basin containing the milk she had drawn by
sucking, from her mistress's breast since this hour yesterday (5th). We
measured it, and found it to fill more than two pint cans. Besides this
great quantity, the child; which was born on-the 1st inst,, has been
suckled every two hours, or twelve times per day; and a towel that had
fallen into the basin was taken out soaked full of milk. If the infant
took an ounce and a half at each time, or eighteen ounces in all, and the
towel a gill, or four ounces, we have here fifty-four ounces of milk
secreted in the course of twenty-four hours. On the 7th of the month I
measured thirty-four ounces that had been drawn by the nurse in
twenty-four hours, though a portion had been thrown away--so that I
suppose she secreted near about the same quantity in the two consecutive
days. Women rarely furnish so considerable a quantity.
It, must be clear to your minds that such a great
functional force cannot exist independently of a vast supply both of blood
and of nerve-force. Accordingly, numerous arteries come from within the
axilla, and from the internal mammary artery; and a great variety of nerve
fibrils, some of which are connected with the sympathetic, pass from
within the chest, while others connected with the axillary branches, ally
it to the cerebro-spinal system of innervation,-serving. to connect the
mammary gland with the whole nervous constitution of the woman, and render
it in the highest degree liable to those development movements that result
in sanguine engorgement and inflammation.
At the period. of puberty, among the first signs of the
change about to be effected in the constitution of the young girl, those
that take place in the breast are observable : the granules of the gland,
and its efferent ducts the galactophorous tubes, acquire a more positive
development; and the hemisphere of the mamma begins to rise from the
general surface of the bosom. But it becomes protuberant, rather than from
an increased amount of the deposit of adipose matter among the cellulo-fibrous
digitations of the gland, than from actual development of the substance of
the glandular matter itself, although that does, as I have said, increase
a little. The nipple, at this period, is very small and is seated in the
centre of the aureole, which is a reddish or rosaceous area, extending
from the base of the nipple a certain distance on the organ, in general
not more than half an inch from the nipple, in every direction. Observe,
that it is of a rosaceous hue, deeper or paler, according to a sanguine,
or
lymphatic, or nervous temperament of the subject. As
the young girl becomes more and more perfectly developed, the breast
becomes more and more augmented in size; so that you should expect a
person of eighteen or twenty to have a larger one than a girl who has just
changed.
The breast is, in general, possessed only of such
sensibility as appertains to the tactile power of the skin everywhere ;
but, upon particular occasions, it is different. For example, many young
persons at the approach of, or during the mensual period, find the breasts
a little larger and fuller, and more sensitive, and affected with sharp
pains which disappear when the catamenia begin to flow freely, and
reappear at the next mensual epoch.
When a, woman becomes pregnant, the breast very
speedily begins to grow larger; the fat deposited upon it is sensibly
increased in quantity, and if the gland be taken between the thumb and
four fingers, it is found that the fascia which incloses the material of
the gland is fuller, rather tense, and has a more granular feel than
usual: in many, it feels as if it were full of strings or, ridges, giving
in some instances a sensation as if one were touching a bunch of
earth-worms beneath the skin. At the time this process of augmentation
within begins, the aureole increases its area, and what is very singular
and worthy of your observation, the corpus mucosum of the skin beneath the
aureole acquires the power of excreting pigmentum nigrum; just as if the
corpus mucosum had now become endowed with a pigmentary membrane like that
that lies beneath the skin of a Negro, a Malay, or an American Indian, but
which does not exist beneath the skin in the Caucasian races. In some
women, the breast grows fat at such a rate that the skin is pushed off
further and further from the fascia which inclose's the gland, and the
milk tubes within, whose termini are upon the nipple, fail to stretch or
elongate themselves pari passu with the rise of the skin. The
nipple in this, case seems to be drawn inwards, so that, instead of its
being a prominent mammilla upon the breast, there appears a depression
like that which the carpenters call a countersink. This countersink of the
nipple is produced in the same way as the pit is produced in the navel of the young growing child; for as the navel is held in,
according to Billard's description, by the remains of the two umbilical
arteries and the umbilical vein, so the countersink nipple of the female
breast is detained within by the unyielding galactophorous tubes, which
refuse to be elongated while the rest of the tissue is being stretched. I
suppose, gentlemen, that if our American ladies were, in the habit of
supporting their bosoms with the pretty Greek strophium, or the Roman
fasciola, which women were accustomed to wear in the olden time, there
would be less occasion to deplore the frequency of this troublesome
retraction of the nipple. If the breast were left free to grow in all its
parts, it is likely that the nipple would be produced, along with the rest
of the tissues, but the wearing of corsets and busks must necessarily
interfere with the development of the organ, and lend a material aid to
the nipple in its refusal to come forward along with the rest of the
structures.
A young. married woman, who should become pregnant, and
who should find that her nipple is becoming countersunk in this way, ought
to apply to the point of the breast a concave disk of very thin hammered
silver, three inches in diameter, with an opening sufficiently large to
allow the nipple to pass freely through it, and having a cylinder, a
quarter of an inch in length, soldered upon the edge of the opening. The
concave of the disk would adapt itself to the form of the areola of the
breast, and the nipple projecting through the opening, and protected by
the cylinder, would have a constant tendency to come forward, and draw
with it its whole fasciculus of galactophorous tubes; so that, at the
termination of the gestation, the nipple might be found in a fit condition
to be seized by the lips of the child, instead of both vexing it and
tormenting its parent with vain attempts to get it into the mouth. I have
seen several women who could not nurse at all on account of this shortness
of the nipple. All such are liable to irritation, and even to suppuration,
in consequence of the impossibility of expressing the milk, formed in
abundance by the granules of the gland ; and from abrasions and cracks of
the nipple, produced by repeated and protracted attempts made with
breast-tubes and pumps and various apparatus for what is called drawing
the breast. After the above explanation, should you be consulted
beforehand as to the treatment of the affection, I should think you will
have no difficulty in giving directions conformable to the wants of the
patient. Ladies will sometimes ask you whether it is advisable to have the
nipple drawn by a young puppy, or by the mouth of a friend or servant. Let
your answer be, that God is all wise; that he could not make a mistake;
and that if it was necessary to have the nipple drawn before the child was
born, he would have had the child born before its birth. All the laws of
life are generic laws; they cannot err; and it is perfectly ridiculous for
a mere human reason to dare to be superior to the will of God, as it is
expressed in the simple words, " the laws of nature." Tell her to
let it alone; it is just as reasonable to draw the nipple beforehand as it
is to give ether to put a stop to the natural pains of labor. Let her
know, that after her child shall be born, she will, after the third day,
or earlier, put it to the breast; and that the moment the child begins to
irritate it with the tongue and lips, she will begin to feel an after
pain--that is a contraction of the womb--for there is surely a connection
between the breast and the uterus which affects them both interchangeably.
To draw the breast, therefore, is to expose herself to the risk of
exciting the action of the womb before the time. Surely, to draw the
breast is to risk exciting the womb into muscular activity.
Somewhere between the first and the seventy-second hour
after the birth of the child, the fluxional movement towards the mammary
gland begins to take effect; and the determination of the developing force
proceeds in the direction of the secretory offices of the granules,
manifesting itself by the production of the milk. The fluid when secreted
flows into the great tubes of the breast, making it hard, voluminous, hot,
weighty, and painful. The whole of the gland being contained within its
fascia, and being now greatly increased in weight, hangs suspended upon
the skin on the front of the thorax. From its weight it prolapses,
stretching the skin, and often increasing the pain of the gland in
consequence of the unequal tension of the several parts of it, caused by
the descent. On this account the breast should always be held up; it
should never be allowed to bang by its own tissue. You would not think of
treating an orchitis without a suspensory ; nor should you think, in like
manner, to take good chirurgical care of an overfilled breast without
providing good means for its support. A Greek or a Roman girl always
supported her breast by means of the strophium or the fasciola, which
passed beneath it you should provide a strophium for your patient. The
most convenient one that can possibly be devised is, in my opinion, a
linen strip of adhesive plaster, half an inch wide and ten inches long.
Place it upon the skin behind the breast on the side: it should then be
attached to the hemisphere, which is to be held properly upwards, and the
upper extremity being next carried upwards near the clavicle, should be
adapted in such a way as to assist the corium to hold up the heavy breast,
which is surcharged with fat, and granules, and bundles of milk tubes.
Sometimes, one adhesive strip suffices, though I occasionally put on two
or even three, in order to give a perfect support. This is far better than
all the jackets, and corsets, and pocket-handkerchiefs that can be
devised--I mean for the early stages of the suckling breast. The adhesive
strip should be reapplied every second or third day. Hold up the breast,
then, with the adhesive strip or fasciola.
In most cases, you would think a suspensory a
sufficient remedy for an orchitis; in like manner, you will find that an
adhesive strophium is a sufficient remedy for the slighter irritations of
the female breast. You may apply it so as not only to support, but gently
and favorably to compress the whole organ. When the breast becomes
overfilled, its sensibility is so greatly increased that the woman does
not willingly suffer it to be touched. You will often find it
incompressible, and actually shining from the polish of its tension. It
has now a power to irritate the nervous and vascular systems equal to the
power of an immense imposthume or abscess; and the constitution will be
found to react upon it, and the woman will have a fever ushered in with
rigors, or even with a severe ague. These rigors and this fever, like
those of an ordinary intermittent or remittent, terminate in copious
perspiration.
The fever is not a tertian, it is an ephemera; it
terminates after a course of nineteen hours from the beginning of the cold
to the end of the hot stage : this is its natural course. But still, a
milk-fever, though so short-lived, is never a matter of indifference ;
because, a milk-fever attacks the constitution of a woman already greatly
modified by gestation and labor and the puerperal state ; and if the
violence of the vascular movement happen to be very considerable, or, if
there have been any topical lesion, or any accident that may have happened
in the course of the labor, it is apt to invite the fluxional movement
upon itself, and thus become a new radiant point, whence inflammation may
extend into the depths of the tissues, or, along their surfaces.
Don't say, therefore, "
it is only a milk-fever,
and requires no special care;" but give it the attention it may
deserve. If the milk-fever should be progressing favorably, and manifest a
tendency to run out its natural course and terminate at its ordinary term
of nineteen hours, your only duty would be to watch it, and take heed that
it do no mischief within the bounds of the economy. Remember, the
milk-fever is a constitutional irritation developed from a radiating
point, videl., the over-sensitive, over-tense tissue of the mammary
gland ; and see, in this reflection, that one indication of treatment is
to deprive the breast of this pathogenic power. Well, but to deprive it of
this power which depends on the tension, you must make the tissues
as flaccid as possible. How? What is it that chiefly renders it tense? It
is the twenty-one milk tubes whose trunks and branches are all distended
to the extremest degree of tension, because they contain at one time eight or ten ounces of
milk, constituting, perhaps, one third of the whole weight of the organ.
Take the milk out, and the breast that you could not indent with the palps
of your fingers will be left perfectly flaccid, completely cool, and
admitting of the freest palpation and handling, without the woman making
any complaint.
Tell the nurse to put the child to the breast often.
How often? As often as it is necessary. How often is that? As often as the
breast becomes hard. For thirty years past, I have told my monthly nurses
these things; perhaps in these very words; nevertheless, I cannot, to this
very hour, go into a lying-in room, where I find a breast in a state of
tension, and the constitution in a state of fever, without being told,
" I did draw the breast, doctor; the child took it this morning."
" How long ago, nurse ?"
" Why, at seven o'clock."
" What o'clock is it now ? twelve, is it not?"
" Yes, it is twelve o'clock."
" So you drew the breast five hours ago, did
you?"
" I drew it at seven o'clock, sir."
" And it has been as hard as a paving-stone
ever-since. Can't you see that if you let the breast remain hard it will
inflame ? This fever will increase and not lessen, and you will expose
your patient to the risk of having, a mammary abscess, or gathered breast,
as you call it."
" Oh ! never do you mind, doctor; I never had a
gathered breast in my life. Do you think I ever allowed a patient to have
a gathered breast ?"
Excuse me, gentlemen, for writing in this style, for I
have at this moment under my care, two mammary abscesses produced by the
faults of two most excellent monthly nurses.
I am sure that you will be able to appreciate the
importance there is of keeping down this mammary tension; for, if it is
not kept down, the tissues must inflame; and inflaming under such
circumstances of great constitutional fluxion, you will not be able to
avert the mischief of the threatened suppuration, except at the expense of
the most vigorous antiphlogistic means. To draw the breast now, and not by
and by, is to save the patient from venesection, from leeching, from
cathartics, from a disgusting series of poultices; and all the pain and
exhaustion of protracted and difficult mammary suppuration. Take heed of
it, then : see if you shall be able hereafter to be more successful than
I, in making the patient herself, or those that attend on her, comprehend
the true influences of mammary tension. If I could give you in this letter but a just notion of the meaning of the
words mammary tension, I should think you were well rewarded for the
perusal of the whole volume, though you got not another useful hint out of
it.
When you find that the tension of the breast produces a
constitutional reaction of great violence, and that the fever is
accompanied with headache, pain in the back and loins, aching of the
limbs, and frequent rigors, you should look upon it as a serious matter ;
which, though it be nothing more than a milk-fever, exposes the woman to
the risk of dangerous local engorgements and inflammations.
You should lessen this constitutional reaction by
opening a vein in the arm; by the exhibition of a cathartic medicine,
whether saline or other; by proper doses of the neutral mixture,.and by
insisting upon the free use of demulcent and diluent drinks. If you allow
the fever to rise to too high a grade, it may be feared that, instead of
coming to its term in nineteen hours, it will become a continued fever,
which will have an inflammatory character, and which may plague you for a
week or ten days ; involving you in the constant necessity of watching
over the patient, and exposing her to the greatest risks.
Sometimes the breast becomes so hard, so rebellious,
that it is found impossible to extract the milk from its tubes; they crowd
each other, acting as compressors upon each other; making it impossible to
remove the accumulation. Under these circumstances, the nipple is apt
become irritated and even inflamed. The frequent sucking of the nipple by
the child, or by various instruments invented for the purpose, produces
cracks and abrasions of the surfaces, and, then you have an ulceration
established upon an inflamed base. Were the ulceration seated upon a
non-inflamed base, it would cure itself: but you will no more cure the
nipple-sore while the whole mass of the nipple itself is in a state of
inflammation, than you will cure a cancer-sore while the ulcer is seated
upon a carcinoma. I do not mean that it is incurable as be cancer-sore is,
for the nipple will at last get well, having in it no heterologue
character; the cancer will not get well, for it rests upon a heterologue
base.
You can have, at present, no idea of the vexations that
women endure in the month in nursing their children from sore nipples ; a
complaint so common, that I am surprised when I hear one of my patients
say she does not suffer from it.
The sore-nipple most frequently consists in a long,
narrow ulcer, wide as a horsehair, and a sixteenth or sometimes an eighth
of an inch long, situated on the side of the nipple. This ulcer is so
small, that it requires a good light to see it ; and even then it often
cannot be detected, except by bending the nipple over to the opposite
side, which discloses it. The ulcer is, at most, a narrow line of painful
granulations ; and it hurts the woman so very much as to render her
unwilling to suckle the child as often as it should be done; which exposes
her to the risk of having an overfull breast. I think it very probable
that many cases of mammary abscess owe their origin to the reluctance of
the mother to encounter the pangs of suckling the infant while these
fissures or cracks of the nipple are uncured.
When one of them occurs in a nipple, the whole
substance of which has become inflamed and hardened, it. is very difficult
to cure it; and it is even difficult to prevent it from increasing both in
length and breadth, since as often as the child takes the nipple into its
mouth to stretch and to pull it, so often is the sore liable to be
augmented. The pain is represented to be of the most intolerable kind; and
it must be, indeed, most insufferable, if one may judge from the
appearance of the mother, from whose eyes tears are seen to stream as she
submits to the pain. I have often imagined the pain to be, in intensity
very similar to that which one feels who has received a bit of sharp
angular sand in the eye, and which vellicates the lids of the globe,
whenever they are moved, producing a pain and irritation that are truly
intolerable. The sore would disappear I presume, in forty-eight hours,
were it not for the necessity of drawing the breast.
In treating such a sore, I generally avail myself of
the antiphlogistic and anodyne power of the nitrate of silver, the contact
of which is, in some instances, sufficient to make a speedy cure, where
the massive inflammation of the nipple will admit of the cicatrization of
the sore.
It is a matter of great consequence to touch only the
granulations, and not the skin itself. To this end I take a fine
camel-hair pencil, and, dipping it in a solution of the nitrate, I
carefully pencil the granulations only ; for I find it easy, with the
delicate point of the pencil, to make the application exactly to the
points I desire to touch. A solution of twenty grains' to an ounce is
strong enough. You will find, in many instances, that the extreme
sensibility of the sore is lessened so much by one contact of the nitrate
as immediately to enable the woman to give suck to the child with much
greater comfort.
Mrs. De Groot, a monthly nurse here, a most sensible
woman, in whose prudence and knowledge of her business I can confide,
tells me that the nipple rarely becomes sore under her method of managing
it. As soon as the child has left the nipple, Mrs. De Groot invariably
cleanses it with a bit of moistened linen. She dries it perfectly, and
then, taking the mammilla between the thumb and two fingers, gently
compresses it, with a view to assist it in disengorging its capillary
vessels that are turgid from the suction. As soon as she has rendered. it
soft and flexible again, she covers it thick with fine arrowroot powder,
and keeps it in that way perfectly dry. I do not remember that the ladies
she has nursed for me have, any of them, suffered from this annoying
disorder.
Dr. Physick taught me to cure a very bad nipple-sore in
a patient he attended with me. He prepared a very delicate adhesive strip
by spreading adhesive plaster on a narrow ribbon, called by the
shop-keepers taste.
" These gaping ulcers," said he, " are
like gaping incised wounds. Their edges are separated too-much; they will
therefore require a far greater quantity of granulations to heal them than
if the edges should be approximated--bring them together then with the
delicate strips of adhesive plaster, and keep them so--they will get well
much sooner." This advice was followed, and the effect was soon
perceived in the amendment of the lady.
Most of the French physicians use, for the treatment,
an ointment made out of the juice of cucumbers--the pommade de
concombres--and it certainly is one of the most emollient of the
ointments. A good deal of it is employed here. In order to be useful, it
should be freely applied.
Borax, dissolved in mucilage of slippery elm, is a very
pleasant wash. It should be put into a salt-mouth phial, the throat of
which is large enough to, receive the nipple. Let the phial be turned upon
the nipple as soon as the child leaves it. If held thus to the nipple a
few moments, the whole surface is effectually moistened by the wash.
Dr. Vanderpool, of Albany, New York, who formerly
attended my lectures in the college, writes lately that he has very little
trouble in healing the sore nipple, whereas formerly he had experienced
much difficulty in curing his patients. The method he uses is, to smear
the aureole frequently with an extract of stramonium.--If carefully wiped
off before giving suck it does no harm to the child, while it speedily
relieves the mother.
Where the nipple has been greatly inflamed and swollen,
I have on many occasions directed a number of leeches, six to ten, to be
applied just outside of the areola: For this end, I cut a disk of linen,
or of diachylon-plaster to fit the areola, leaving a fenester for the
nipple. The leeches cannot puncture the areola, itself, if this precaution
be taken--but their bites are all made beyond the circumference of the
disk. You should not allow them to wound the aureole, because it renders
the act of sucking more painful, and because the erythema that always
attacks the leech-bite would pass on to the nipple and aggravate, instead
of diminishing, its inflammation.
It is very bad when the end of the nipple becomes
abraded and inflamed, for then the inflammation runs along the milk tube
deep into the substance of the mammary gland ; and when it does so, a
great difficulty is encountered in effecting a cure, short of the process
by suppuration : when. the end of the nipple, therefore, is abraded and
ulcerated, you should give it a most careful attention, with a view to
prevent so great a misfortune.
Inflammation of the mammary gland, tending to abscess,
is a warrant to order a venesection for a woman who is strong enough to
bear the loss of blood, and there are few who are not strong enough, since
those who are not, will, in general, not be found prone to these
inflammations. You ought not then to hesitate to bleed for an inflammation
of the gland, when the disorder threatens to be severe.
Leeches freely applied, if they be not set upon an
inflamed portion of skin, are very laudable. Many a hard nodule,
threatening milk abscess, has been removed by twenty or thirty leeches;
the operation to be repeated if the case demand it.
A poultice is manifestly a useful remedy. But poultices
long applied to the delicate skin of the mamma are apt to bring out an
eczema that adds to the discomfort. I think I have never had any such
additional trouble when I used a poultice made with bread and milk
thickened with the petals of chamomile. It is a habit or routinism of my
practice, and I venture to recommend it to a trial under your direction.
When the breast must suppurate, it ought to be favored
by the use of demulcent poultices. Powdered slippery-elm makes a good
one--so does flaxseed meal--but probably none is better than bread and
milk with chamomile.
When the suppuration has taken place, the matter ought
to be discharged by means of a lancet, as soon as the abscess fairly
points. When the cavity is become empty by the discharge of the pus, let
the breast be compressed by means of strips of adhesive plaster, which
constitute the most convenient suspensory and compress for the organ. I am
confident the use of these adhesive strips has enabled me many times
readily to cure a breast, which I should vainly have endeavored to cure in
double the length of time by any other kind of dressing.
The breast having suppurated, and the pus being
discharged, whether by a spontaneous opening or by means of the lancet,
milk is sometimes seen to flow out together with the purulent matter. Such
a waste of the milk prevents the aperture from healing; and the cavity of
the abscess becomes a milk-fistula, which continues for an indefinite
period to discharge milk. When I find such a one, I push to near the
bottom of the canal a very small bougie, made extempore of cere-cloth.
Filling the orifice of the fistula, and probably irritating the internal
granulations to a more healthful activity, the bougie, generally, soon
arrests the flow of milk from the orifice. The bougie becomes daily
shorter, at each successive repetition, and the fistula heals.
If a woman have a suspicious nodule of long standing,
in the breast, she ought not to nurse the child. The constant alternations
of fulness and flaccidity, and the augmented vital activity required to
carry on the secretion of the nutriment, expose her to the danger of an
inconvenient increase of the tumor, and to inflammation radiating from its
superficies. Let her wean the child by giving it
to a wet
nurse. If you decide to remove the tumor or nodule by the bistoury, let it
not be done until the milk has completely disappeared. The breast is not
fit for the surgeon while it is a secreting gland.
And now, having nothing further to propose as to the
breast, I shall bring this letter, the last of the series, to a close.
I wish, my dear friends, these letters were more worthy
of your perusal; and I might, doubtless, have rendered them so, had I
allowed myself, which I could not, more leisure from the daily business of
my vocation, for their composition. Many of them have been written while
waiting on women in labor ; and most of them at night, after the toils and
anxiety of the day's practice ; more than half of them, while suffering
under an unspeakably distressing hemicrania.
But I had made the promise to write and publish a
series of letters to you, on the subject of Woman and her Diseases--
letters in which I would speak as nearly as possible in the same tone and
manner I should employ in speaking on the subjects, with any one or two of
you in my library here, where I am now writing. I have used that very
manner in these communications; and you, who remember my manner of
speaking to you in the lectureroom, will be able to judge whether or no I
have done right in using a style as simple and natural as that you have
been accustomed to in my public instructions.
Some critics have blamed me, and some endeavored to
ridicule me for using so familiar a method, and as I am aware that no man
has a right to print a bad book, nor even to apologize for faults in any
book. of his own making, I do not pretend to do so on the present
occasion. I do, however, feel desirous that you should not forget the
scene and the occurrences that so suddenly prompted me to engage in this
task; nor overlook the fact that I did not begin these letters of 698
pages until about the middle of last May.
I have found the mechanical labor of it severe,
" Sed tua me virtus tamen, et sperata voluptas
Suavis amicitiæ, quemvis efferre laborem
Suadet ; et inducit noctes vigilare serenas
Querentem dictis quibus, et quo carmine demun
Clara tuæ possim præpandere lumini menti
Res quibus occultas penitus convisere possis."
These beautiful lines of the poet Lucretius, I quote
from the Treatise de Rerum Natura, and I do so in order that the
dead Roman might speak, and say, in better language than any I could
indite, how strong the motive that has induced me to this labor. Pray,
then, receive this work of his head, his heart, and his hands, from your
former Instructor, with kindness, and assist him to invoke for it the
favorable consideration of all our brethren of the Medical Profession, who
I hope will see in it the evidences of a sincere desire to promote the
usefulness, and therein the dignity of our honorable vocation.
I pray you ever to look upon the medical profession,
not as a business, but as a great Morality, not as a trade, but as a
Mission appointed by God for the benefit of the children of men.
Farewell, dear young gentlemen,
and believe me, affectionately, your friend and respectful servant,
CHARLES D. MEIGS.
PHILADELPHIA, 26th Nov. [ 1847 ]
324 Walnut Street.
[ From: Woman: Her Diseases and Remedies. A Series of
Letters to His Class. By Charles D. Meigs, M. D., Professor of Midwifery,
and the Diseases of Women and Children, in the Jefferson Medical College
at Philadelphia; Member of the American Medical Association; and of the
American Philosophical Society; and of The Council; late Vice-President of
the College of Physicians of Philadelphia; of the Swedish Society of
Physicians at Stockholm; late one of the Physicians to the Lying-in
Department of the Pennsylvania Hospital; Etc. Etc.
Fourth Edition,
Revised and Enlarged.
Philadelphia:
Blanchard and Lea. 1859.
Entered
according to the Act of Congress, in the year 1859, by Lea and Blanchard,
in the Office of the Clerk of the District Court of the United States in
and for the Eastern District of Pennsylvania. Philadelphia: Collins,
Printer, 750 Jayne St. ]
|