CARE AND TREATMENT OF THE Nipple in the Gravid and Puerperal States By y S. MARX,' M.D. NEW YORK Reprinted from the Medical Record, February ii, 1893 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING’CO. 201-2i3 East Twelfth Street i §93 CARE AND TREATMENT OF THE Nipple in the Gravid and Puerperal States By / S. MARX, M.D. NEW YORK Reprinted from the Medical Record, February 11, 1893 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1893 CARE AND TREATMENT OF THE NIPPLE IN THE GRAVID AND PUERPERAL STATES.1 The paper I present this evening is not dogmatic. Cer- tain theories which have been formulated by the writer will be presented to you as suggestions, with the hope that such theories which are founded upon actual experi- ence in practice shall strike you as being rational; nor is there any intention to present anything startling or fantastic, but common sense ideas which have been the result of much thought and study. Of late, very little has been said or done in advancing anything new in the way of treating, with either a prophylactic or a curative aim, this very troublesome and painful disorder. It is with the one idea of provoking an active discussion that the subject of lesions of the nipples in the gravida and puerpera is presented. It will be wise for us, and you will pardon me for being so exacting, to study for a few moments the changes that occur in the nipple during early pregnancy. One of the earliest symptoms, whether objective or subjective, presented to us in the pregnant woman, is a change in the nipple and breast. Before or at the second month the changes in the nipples are very marked. They become sensitive, erectile, larger, and turgid. The epidermis which covers the papillae becomes somewhat thickened; according to Montgomery, they are covered by branny scales. These protective scales are formed by the drying of colostrum upon the nipple. 1 Read before the Metropolitan Medical Society, January 25, 1893. 4 It can be milked out of the breast at all times by gently stroking the organ. Thus we have produced by nature a perfect protection to the nipple from external injury. When, from friction, rubbing, harsh manipulations, this protection is removed in places, you get the familiar erosion of the nipple. If entirely rubbed off, you have an uneven, bright red, puckered surface, presenting the picture of a sensitive, painful, fissured, or excoriated nipple. But when the nipple is protected from injury, either wilful or accidental, a hardening or seasoning of the papillae occurs under these scales, which, to my mind, is likened to the healing of a wound under a scab. What I wish to get at will probably become entirely clear to yourselves when I go on to say that, when we read in the ordinary text-books about the care of the nipple and its treatment before confinement, how very paradoxical and perverted is the advice given us. We simply fight against the power of nature. What she in her wisdom has given us, we attempt to destroy and cir- cumvent. Nature gives protection to the nipple ; we, to prepare the nipple, or mollify some whimsical pa- tient or pesky old woman, by our frictions and falla- cious rubbings remove nature’s own protection, so es- sential to the tender nipple’s well-being. Could you think of disturbing a wound healing under a scab by rubbing, scraping, and meddling with that part until the scab is off ? I hardly think that such treatment or method would present itself to you ; but with the nipple, in a miniature way, it is another thing. You are seeing it done, have had it done, and will continue having it done until I can bring you around to my side and to the side of nature. Enough as to theory, now as to practice. You will ask, what proof, practical proof, have you to substantiate these statements ? My answer is, all the proof that practice and close observation can give. Of this, more later on. In the “ American Obstetric Encyclopaedia ” 5 the following can be read : “ If, as is always with primi- parae, the nipples have been properly subjected to pre- paratory treatment, trouble does not often occur, consist- ing mainly in promoting its projection, size, form, by drawing it out daily and hardening the epidermis with daily applications of astringent alcoholic solutions.” Others advise us, but all agree as to the manipulations night and morning, to use locally brandy-and-water, tincture of arnica, benzoin, etc. This presents to you the consensus of opinion of most modern writers and teachers. With one exception, they all agree as to the manipulative procedures. This exception can be found in Schroeder’s “ Midwifery.” In this book it is stated that the breasts are to be kept warm and protected from pressure. The nipples only to be hardened when ten- der and sensitive from pressure and irritation, and then only by gentle washing nightly with spirit and cold water. If inverted, very careful and gradual eversion should be practised in order not to start up uterine contraction. What greater irritation, local and general, especially lo- cal, to a sensitive nipple can you get than by rubbing, pulling, washing with all kinds of astringent and irritat- ing drugs once, twice, or more times a day ? I voice his sentiments, and even go further and say, let the nipples alone, absolutely alone, only for cosmetic reasons use cold ablutions ; protect them from external irritation and pernicious corset-bones and corsets by appropriate shields or plentiful absorbent cotton, and you will see fewer excoriated and fissured nipples, fewer infective mastites, and smoother convalescences from child bed. When I look back to my hospital practice in mater- nity wards, and reflect how few sore nipples and breasts we had to deal with, and compare this with the condition I formerly met with in practice where I encountered so many such, I can only attribute it to meddlesome inter- ference. Certainly women, admitted to hospitals shortly before expected labor, who are filthy, half-starved and 6 clothed, and ignorant, know nothing of the prophylactic treatment of their nipples. And yet it was quite infre- quent to see as a result sore nipples and breasts. In what other way you can account for it I do not know. It has been claimed that the rare occurrence of mastitis in hospital practice is due to the uniform and careful ap- plication of the breast binder ; but in this I do not agree. Believing as I do, that all mastites, excepting and exclud- ing traumatic influences and improperly regulated nurs- ings, are due to an infection specifically caused by the entrance of toxic matter by way of fissures and erosions of the nipple, I do not see how the breast-binder can possibly prevent a mastitis. This much I will admit, that when a mastitis is threatening, a tight and uniform application of a stout breast-binder will do more to dis- perse the inflammation than any other remedy in our power. The infrequent occurrence of sore breasts, in my opin- ion, is due to the fact that the nipple during pregnancy has little or no attention, protected only by that branny exudate which comes from the breast during early preg- nancy. But in private practice, in spite of your prophy- lactic treatment, how often do you see women who do not have sore, excoriated, and fissured nipples ? Since introducing my theories into practice I see very few such complications ; and when a gravida asks me what she should do for her nipples—and how few do not ask this question—my invariable answer is : Stop wearing corsets, if possible ; instead, wear a corset-cover to support the breast. Protect your nipple with plenty of absorbent cotton, and forget you have a nipple. Nothing more, unless the nipple is inverted, and then gently drawing it out three times a week by means of a breast-pump will remedy that defect. When the nipples are tender and sore, no other measure is recommended than the appli- cation of a ten per cent, ichthyol-lanolin salve. This in a few days heals the parts perfectly, i 7 Before going on to the treatment of lesions of the nipple during lactation, I wish to call your attention to the diagnosis and dangers of such lesions. The diag- nosis in most cases is simple. The presence of pain and visual inspection are all that is necessary. But there are puerperal cases which present general symp- toms—high fever, rapid pulse, severe pains in the head, back, and abdomen—which we can refer to minute nip- ple lesions only after a process of careful exclusion. Local inspection helps us but little, for the nipple, though a little tender, fails to reveal the minute rhagades which are always present in these cases. This condition occurs in those nipples apparently healthy which are large, hard, prominent, and present an almost even and unbroken surface. The puerpera rarely complains of pain in the breast during nursing, but suffers from reflex symptoms. The course of the temperature and the general symptoms are so very peculiar that to one see- ing but a few of these cases the diagnosis is not so diffi- cult after all. The pains, though at some distance from the breasts, the extreme nervousness, the temperature, the rapid pulse, the anxiety, are all markedly increased during the act, or at least at the beginning, of the nursing process. After the act the patient is more comfortable and quiet, but the temperature and pulse do not fall to the normal between the nursings. The fever chart would be characteristic if taken at short intervals. At first a rapid rise, to remain at its height while the infant is at the breast, then a gradual fall to a subfebrile condi- tion. In chronic cases of this class I have several times made the diagnosis of minute rhagades by carefully tak- ing the temperature four times in twenty-four hours. For example, in some women after the puerperal period a fever persists for days, weeks, and months. A diag- nosis seems impossible. She is treated in every possible manner by different specialists, but still the fever per- 8 sists. The temperature chart would show a higher degree of fever during nursing, and in some a marked temperature in the morning, higher than in the evening. And this for this reason, that the child in many cases, especially among the lower classes, suckles the greater part of the night and constantly. This in itself, on account of the constant irritation of a small fissure, is enough to keep up a temperature, and a high one at that. Wean the child or use proper local measures, and your temperature disappears. Now as to the dangers : 1. Chronic ulcer of the nip- ple, ulcer with sloughing. 2. Chronic eczema, with the possible predisposition to mammary cancer. 3. The most frequent is a severe acute mastitis, with the possi- bility of general septic infection. As mentioned above, it is my belief that there is hardly a mastitis which is not due to nipple lesions ; for, a, in every case a fissure or erosion, no matter how small, can always be found ; b, as a rule the mastitis is found on that side of the breast cor- responding to the situation of the lesion on the nipple; c, we have a point from which the infection may be carried into the milk-channels ; d, mastitis without lesions of the nipple is certainly rare. In spite of the fact that patho- genic cocci have been found in human milk, yet it requires an extra stimulus to start up a mastitis. Cohn and New- man,1 as a result of the examination of milk from a healthy woman, which was obtained under all antiseptic precau- tions, state that the milk nearly always contains micro- organisms, usually pus cocci, especially the staphylococ- cus albus. The newer the milk the fewer the cocci. The same get into the breast from without; therefore, the first milk drawn, that situated in the periphery of the gland, contains a greater number of cocci than that drawn later. Fermentation does not take place on account of the pus cocci, and the milk always has an alkaline reaction. The fact that so many drugs have been recommended 1 Virchow’s Archiv, Bd. 126, Hft. 3. 9 for the treatment of this disorder, shows us at once how difficult it must be to treat such cases, i. Insure support and rest to the organ by a firm binder with holes for the nipples, to allow their exposure for the escape of milk and application of remedies. 2. Diminish the frequency of nursing as much as possible, even to the extent of tem- porary weaning, in order to allay both local and general irritation. Frequent nursing delays healing of the lesion. 3. As a palliative measure, a five or ten per cent, cocaine solution, applied shortly before putting the child to the breast, will certainly insure perfect freedom from pain. If the nipple be generally tender, without a break in the continuity of the surface, a ten per cent, ichthyol-lanoline ointment has given me the best results. When fissures or erosions are present, having an unhealthy, uneven, deep-seated, sloughy appearance, a thorough cauterization with lunar caustic, or better still, a brisk curetting with a small dermal curette preceded by cocaine to quiet pain, and followed by some stimulation, as by the ammoniated mercury ointment, balsam Peru, or aristol in substance, or other antiseptic drug, is all that is necessary. Where there is a deep-seated, healthy ulcer present which fails to heal in spite of all our remedial agents, I believe that the passage of one or more fine sutures might prove the ideal method of treatment, if combined with perfect rest for thirty-six hours and firm breast compression. During the last two years I have treated all fissures and erosions of the nipple with a strong ichthyol ointment, and so universally successful has it proven that I have discarded all drugs for this one. Three cases of my own I can distinctly recall to mind at this moment, in which it acted like a charm, in quieting the pain and causing rapid healing. In a fourth case which I treated, the phy- sician in charge had faithfully tried all the remedies which are commonly used. The ulcer surrounding the nipple was deep, irregular in shape, and angry-looking. In a short time the ichthyol ointment cured it. The condi- 10 tion of this nipple was undoubtedly due to the regular washing with a bichloride of mercury solution. In my experience no severer irritant can be applied to the nipple than a bichloride wash or carbolic solution, no matter how weak they may be. The breast and nipple show a decided antipathy toward these antiseptics, and in my opinion they should never be used. Should it be desirous to use an antiseptic solution, a one per cent, creolin or Thiersch solution could be recommended. The ichthyol ointment I use is twenty-five per cent, in strength. It should be constantly applied. Of late I have used the formula recommended by Oehren in the Therapeutische Monatschrift, No. 2, the composition of which is: IJ. Ichthyol, 4.0; lanolini et glycerini, aa 5.0; olei olivari, 1.0. The advantages he claims for this ointment are that it soon checks the excruciating pains of suckling. The fissures rapidly heal, without taking the child from the breast and without necessitating the use of nipple shields; owing to its consistency the salve can be easily and thoroughly washed off. The salve is non-poisonous, and even if the nipple be not washed off, no harm is done the child. In concluding, yet a few words concerning a threatened mastitis. As soon as a mastitis threatens, apply firm, even compression by means of a binder of strong cheese-cloth. A roller bandage, so much in use in former years, should not be applied, because the pressure is not uniform and certainly predisposes the formation of lumps in the breast. Under no condition should the inflamed breast be rubbed or massage instituted; no matter how gently done, it increases the irritation and general inflammatory trouble. The corresponding arm should be tied to the side, nursing should be postponed for a number of hours, and absolute rest should be insisted upon. Locally, it is my custom to use nothing but iced lead-water applica- tions regularly applied. Internally, the patient is given one large dose of iodide of potash, three grammes (45 11 grains) in seltzer or milk. To increase the depleting action of this drug, 3 j. of sal. Rochelle is given hourly until the patient has a number of large watery evacua- tions. Such is the treatment in cases of threatened mastitis, and I am happy to say that the results have proven very satisfactory. mi Lexington Avenue.