CHAPTER XI.

"Mulieri si velis menstrua sistere, cucurbitula quam maximam ad mammas appone."-HIPPOCRATES, Aphor. 50,

Sect. 5.

MAMMARY SYMPTOMS OF MENSTRUATION.

In woman, the mammary glands are so far removed from the organs of generation, that one may well admire how they can be knit together by strong sympathies, and the more so, as we look in vain for voluminous nerves connecting the breasts with the ovaries.

If such nervous cords of communication do not exist, it shows that they are not required by the sympathetic actions of vegetative life. Without undervaluing the influence of the inosculation of the epigastric and mammary arteries in the production of mammary symptoms, I think it right to ascribe them principally to the ganglionic nerves, which, travelling along the ramifications of the vascular system, and plunging into their terminations, are the media of communicating that harmonious action by which the various organs of vegetative life seek to maintain the preservation of the individual, or the maintenance of the race. The ovarian nisus maintains the human race not only by determining the phenomena of generation, but also by its influence over the glands destined to supply the infant with its first food. This influence of the organs of production over the breasts, although generally admitted, is not sufficiently attended to; indeed, the mammary symptoms of menstruation and of diseases of the reproductive organs are much more frequent than it is supposed, not only during menstruation, but during connexion, conception, pregnancy, ovarian and uterine disease, and cessation. Modesty prevents their being spoken of by women, and practitioners avoid questioning them on what is not likely to afford a therapeutical indication.

Menstruation.-A marked development of the breasts coin

cides with first menstruation, and their permanent development is proportionate to the healthy or unhealthy mode in which puberty is established. Moreover, this influence of the ovarian nisus over the breasts is twofold, as was its influence over the whole system; it is both permanent and periodical, for, besides the permanent action of the ovarian nisus on the breasts, they are reacted on every month by the same force. Thus, out of 419 women, the breasts were said to be habitually painful during menstruation in 169; and B. de Boismont has noted this occurrence in 100 out of 360 women. With regard to the nature of the mammary symptoms, they varied considerably. A periodical swelling was the most frequent symptom, generally uniform, sometimes accompanied by local engorgements, as they were said "to feel hard," "in knots," or “lumpy,” and the superficial veins became more apparent. The mammary swelling was generally painful, though in some cases there was "no pain, but only enlargement."

With regard to the nature of the pain experienced, it varied according as the breast itself or the nipple was the seat of pain. The breast itself is generally spoken of as being "tender," "sore, as if bruised," or of being subject to an ❝aching," "gnawing," dragging," "shooting," or " throbbing pain." The nipples were frequently swollen, and became redder, darker, and sometimes secreted a little saline fluid. Their pain was generally described as "smarting," "tingling,” “darting,” “grinding," or "pricking pain." "Twitches, or pins and needles," are sometimes complained of, and the pain in the nipples, frequently experienced by a strong-looking woman, was so great as sometimes to cause her to faint. This will remind the reader of the agonizing pain sometimes experienced by those who suffer from sore nipples. Married women sometimes compare the breast pain of menstruation to the draught of milk. In five of those who experienced the mammary symptoms, one breast alone was habitually affected, without any reason to explain this peculiarity. Mammary symptoms generally precede the menstrual flow by a day or two, or occur during the first days of its duration. Their absence generally coincides with a menstrual flow of short duration, and of an ovarian nisus below par. When the menstrual function is painfully performed, the mammary

symptoms are frequently increased; and sometimes, without this being the case, a neuralgic affection of one or both mammary glands arises in the midst of a menstrual epoch, and continues for months, with exacerbations at each recurring catamenial epoch. The breast is uniformly swollen, without increase of heat, and the pain is great, and much increased by moving the arms. I have seen this singular affection in young women of the healthiest constitutions, and in whom it has resisted the long-continued application of various narcotic preparations. Landouzy found the left breast alone affected in four out of five cases.

Sometimes menstruation will originate a hard and painful swelling of some portion of the mammary gland, which may last for months and for years, being always worse during the menstrual process. I have now under my care a lady, aged twenty-four, suffering from chronic inflammation of the body of the womb, which has lasted for many years. Her father first consulted me in 1853, for hard swellings in both of her breasts. They had been thought cancerous, but I consider them to be an instance of induration of the glands, the result of morbid menstruation in an unhealthy subject. Each breast is a flaccid bag, in which the mammary gland can be felt as a hard, flat cake, with sharp edges, well detached from the ribs. The pains in the breasts are often so severe as to prevent sleep for a fortnight before menstruation, amending during the flow; and as this state of things has now lasted nine years, it cannot be cancer.

A hard and painful swelling of a portion of the breast became apparent in the wife of an eminent surgeon. It was pronounced to be cancerous by several surgeons, but Sir C. Locock and Sir B. Brodie thought it benignant; and this mammary tumour was the first indication that the menstrual function was going to be re-established after fifteen years' absence. The painful swelling then subsided, the lady became pregnant, and has had three children, although Simpson had previously given as his opinion, that she would never have a child, and would die in childbed should pregnancy occur.

The influence of the ovaria in the production of mammary tumours is a matter for investigation. In the case related by S. C. Houston-American Jour. of Med. Science, Aug.,

1834-it is fair to suppose that the enlargement of the ovary produced the hypertrophy of the breast. In this case the mammæ enlarged much more than usual at first menstruation, and became enormously hypertrophied in the following years of virgin life. On opening the body, the ovaria were found to be larger than usual, and apparently diseased; the uterus did not exceed the ordinary size in females of the same age.

I have twice seen distinct ecchymosis of the skin covering the breast, without being caused by external violence; and it is reasonable to admit that small hæmatic cysts of the breast are sometimes the result of the menstrual process. Menstruation had been irregular or suppressed in most of the cases seen by Velpeau.

CONNEXION. The undeveloped nipple is a sign of virginity, and in some women the breasts are always made painful by connexion, and become larger.

PREGNANCY.-Its influence on the mammæ is well known, and has been ably demonstrated by Dr. Montgomery.

CESSATION. I have noted mammary irritations and swelling in 14 out of 500 cases of cessation, but I think it is more frequent, and may help to induce the belief that pregnancy has taken place. In two of Dr. Kirby's cases of mammary irritation, the patients were fifty years of age. It is well known that, in general, the mammary glands become atrophied after the cessation of menstruation, although the breasts may appear voluminous from the deposition of fat in the surrounding cellular tissue. It would be well if the menstrual function were always noted by those who record cases of this description. Thus, out of four cases published by Dr. Kirby Dublin Medical Press, Dec., 1852-this is omitted in three. Spontaneous ecchymosis sometimes marks the breasts at this period, and Dr. Semple has published a case, in which a bloody discharge from the nipples continued every month, for five years after cessation.

OVARIAN AND UTERINE DISEASE. It will be seen that the painful swelling of the mammary glands is sometimes a symptom of ovaritis, of chronic ovarian tumours, and of all uterine affections, particularly when the body of the womb is affected. When impelled to action by diseases of the repro

ductive system, the breasts frequently discharge mucus, and sometimes a milk-like fluid.

I shall relate a case of internal metritis, in which both the breasts, but particularly the left, have repeatedly appeared as if an abscess were forming, and a large amount of milky fluid passed from the nipples.

THERAPEUTICAL INDICATIONS.

1. The avoidance of pressure from ill-made stays.

2. The gentle anointing of the breasts with camphorated liniment, with or without belladonna.

3. The application of a cotton-wool poultice.

4. The insurance of healthy menstruation.