It's not often that I have to disagree with Jack, but now that I know he
won't be sobbing into his pillow I feel it's OK to go ahead (he knows we
love him in Oz). Sez he:
A blocked duct is not something you "just notice".  Any mother who has had
one knows that.  It is suddenly there, it usually takes up a fair part of
the breast and it hurts--a lot.  Antibiotics are not appropriate for a
blocked duct, and normally blocked ducts resolve within about 24-48 hours,
though, sometimes it takes longer.  Two weeks is not what blocked ducts are
all about, except really rarely.

Well, I'd disagree. He's talking about just one part of the spectrum that I
discuss as obstructive mastitis, the non-infective variety: pain,
inflammation, extensive breast involvement. Blocked ducts can be due to:
* structural problems: disrupted ducts;
* corpora amylaceae, concretions of casein and calcium that develop and
obstruct a duct;
* plugs of fatty material, origin uncertain, maybe the old inspissated milk
we used to read about;
* galactoceles developing from a duct that's draining poorly (I had one in
my breast for maybe 18 months; needle aspiration wasn't pleasant and I had
no desire to have surgery to remove it);
* anything traumatic (pressure, bruising etc) that creates local tissue
damage or leakage of body components into places they shouldn't be,
activating the immune system to get in there and clean up.
Which is the stage we notice the blockage, usually. After it's become sore
and hot and so on.It was blocked for some time before that, and in some
cases has been blocked for quite a while, and it's not noticed unless you
go looking or it gets worse. Busy mothers often overlook breast
palpation...

Living with scar tissue in the breast teaches you that you are always at
some risk of poor drainage due to duct blockage, always have some lumps and
bumps that need keeping a finger on on and massaging if (when you
investigate) they seem a bit tight and sore. They don't shout out hey, I'm
here. In fact it's usually only after  a few doses of mastitis in the same
area that you begin to take preventive action and look for them. Most
long-term breastfeeding mothers with fluctuating milk supplies eg in the
second year learn to notice after a few doses of mastitis (this type never
needs antibiotics if you get to it early, and probably when antibiotics
seem to work wonders it's because they enhance phagocytic clearance, not
because they kill bugs that weren't there to kill. High dose vit C and so
on work wonders too.)

This is partly a semantic difference: North Americans tend to talk about
blocked ducts as though they were non-infective mastitis, and mastitis as
though it was breast infection (which it sometimes is, but more often is
not, in my experience. I know Jack agrees with me on this point too: I
think we've had this conversation so I won't take time on it.) Just dealt
with another two cases of mastitis in the last month: first mother as Jack
described, lots of breast very tender, second mother at the lost-the
plot-feverish weeping not coping stage, and I just explained to each very
simply what the problem was, what she needed to do, how to assess if that
was working, and told her to call me back that evening (earlier if she was
in any way worried) when I fully expected she would be fine. Both were.
Both have been since. Both will know what to look for and what to do when
it happens again, as it almost certainly will.
Now the lump described may be more sinister, and it's always wise to check.
But it could well be a galactocele or a blockage that hasn't become
inflamed...
Let us know the outcome.

Maureen Minchin, IBCLC. Christ Church Vicarage, 14 Acland St., St.Kilda,
Vic. 3182 Australia. tel/fax: 61 3 9537 2640
"Taking paths of least resistance is what makes rivers - and people -
crooked." poster in Palmerston North NZ bookshop...