Pus in the breast

The importance of a breast abscess is less for a mother than for her child, who may cease to be breast-fed as a result of it, and be subject to all the hazards of being bottle-fed, particularly marasmus. So your main objective must be to see that when you have treated her abscess, she continues to breast- feed.

Acute septic breast infections usually occur during the second week of the puerperium, in a breast which is either engorged, or has a cracked nipple. Antibiotics alone are only effective if you give them early, during the phase of acute cellulitis. As soon as there is a definite lump, incise it.

Avoid these common mistakes: (1) Don't delay incision, and don't continue with antibiotics alone after an abscess has formed. The mass may fail to resolve, and become so hard (an ''antibioma') that you cannot distinguish it from carcinoma. (2) Don't wait for fluctuation, or for the abscess to point. If you do, she will suffer much unnecessary breast destruction. (3) Provided that she does not present so late that breast-feeding is impossible, don't take her baby away from her breast. He is much the best way of keeping it drained. (4) Don't suppress lactation with stilboestrol, its effects are temporary anyway. Finally, (5) don't forget to insert a drain.

Subacute or chronic recurrent abscesses are unrelated to lactation, and are less painful. They are usually close to the areola, are often associated with inversion of the nipple, and they commonly involve both breasts, either simultaneously, or one after the other. Often, a fistula of a mammary duct is present. If the lesion is localized, you can excise it, as in Fig. 21-1.

Fig. 21-1 A BREAST ABSCESS AND A FISTULA. A, if an abscess points at the areola, or near it, make a circumferential skin incision at its margin. Elsewhere in the breast, a circumferential incision is preferable to a radial one, which leaves an uglier scar. B, insert your finger and break down all loculi. C, loosely pack the cavity. D, the cavity has extended below the incision, so a dependant drain has been inserted. E, and F, excising a fistula of a mammary duct. Both ends of the fistula are being excised, including 2 cm of skin distal to the distal opening. After Rob C and Smith R, ''Operative Surgery'; (2nd edn), p. 289. Butterworth, with kind permission.

BREAST INFECTIONS For the general method, see Section 5.2.

ANAESTHESIA. Give the patient a general anaesthetic. If you use local anaesthesia, which is not very satisfactory, be sure to premedicate her well with pethidine.

ABSCESSES [s7]IN LACTATING BREASTS INDICATIONS FOR INCISION. (1) An area of tense induration. You will feel this most easily when her breast is empty. (2) Pain which is severe enough to have kept her awake the previous night.

Use the tip of your finger to feel for the point of maximum tenderness. Run your finger firmly across the oedematous swelling: you may feel that its centre is slightly softer than its edges. If you are in doubt aspirate it with a needle (5.1).

CAUTION! Don't wait for fluctuation.

INCISION. If an abscess points at the areola, or near it, make a circumferential skin incision at its margin. Elsewhere in the breast, a circumferential incision is preferable to a radial one, which leaves an uglier scar. If you are going to get a finger into an abscess, it will have to be at least 2 cm.

Cut through the skin and subcutaneous tissue. Push a long haemostat into the abscess, and open its jaws. Pus will ooze out. Feel every part of her breast against the haemostat, and try to enter all its loculi. Remove the haemostat, and use your gloved finger to break down any septa between its loculi. If it is in her subcutaneous tissue, feel for a deeper extension.

Insert a drain, and apply a dry dressing. If you wish, you can pack a small cavity; but if you pack a large one, the bulk of the dressings may interfere with breast feeding.

If she has a large abscess in a lower quadrant, make a single incision in the lower part of her breast. There is no need to make a main incision, and then another counter incision inferiorly to provide free drainage.

If you cannot find any pus, the lesion may be an anaplastic carcinoma, so send a biopsy for examination.

If milk flows from the wound, reassure her that it will stop, provided breast-feeding is re-established.

CAUTION ! (1) If she has no fever, or throbbing pain, consider the possibility of a carcinoma. (2) Follow her up carefully. Another abscess may form.

BREAST-FEEDING must not stop! Let her baby continue to suck from her normal breast and, as soon as possible, from her infected breast. But don't let him suck from the infected breast if: (1) Its nipple is cracked. (2) Pus comes from it. If so, express her milk, by hand or with a breast pump. Discard it if it is obviously mixed with pus, otherwise feed it to him. As soon as he can fix on to the nipple, encourage him to suck from it.

If she presents late, when breast feeding has become impossible, incise and drain her breast, and give her an antibiotic to hasten the resolution of the inflammatory oedema. Start expressing her breast as soon as possible, and don't discharge her until breast-feeding has been re-established.

SUBACUTE AND CHRONIC ABSCESSES. Be sure to take a biopsy for tuberculosis.

If: (1) she has a small opening discharging pus, at or near the areolar margin, or (2) recurrent abscesses continue to reappear at the same site, near her areola, she has a mammary fistula (sinus). Examine her during an quiescent phase. See if you can pass a probe from the site of the abscess, through to her nipple. If you can, a fistula is present and you may be able to excise the whole lesion, as in E, and F, Fig. 21-1. Make the incision round the fistulous track, and continue it 2 cm distal to the fistula. There is no need to remove more than 0.5 cm of skin on either side of the track. Deepen the incision to expose the underlying tissue, and excise the fistula. Be sure to excise the central part of the duct, because if you leave it behind, the lesion is sure to recur.

RE-ESTABLISH BREAST-FEEDING IN AN INFECTED BREAST Fig. 21-2 DRAINING A BREAST ABSCESS. This is a less schematic figure than the last one. If the pus could have been reached through a circumareolar incision, it would have left a much better scar! Adapted from an unknown source.