Scarlatina. To prevent or cure nephritis, inject 1 c.c. of oil of turpentine into the outer aspect of the thigh and two days later give twenty-five drops by the mouth in capsule or emulsion. In severe instances repeat on opposite thighs on successive days. -TOBEITZ.

Ethyl Chloride and Nitrous Oxide.-Ethyl chloride compares favorably with nitrous oxide, in that the period of anesthesia is longer, and that the condition of analgesia is more marked. An insufficient dose of nitrous oxide allows a patient to feel the pain of an operation, although he may be unable to complain; whereas with ethyl chloride a patient apparently is conscious of no pain, though he may struggle and phonate. With an improved mask, and an increased knowledge of the drug and its administration, combined with the portability of the apparatus, etc., I think we have in ethyl chloride an exextremely safe and useful anesthetic.

-FRANK H. ROSE. Bristol Medico-Chirurgical Journal, March, 1902.

Gastric Hyperacidity.—Silver, belladonna, or extract of cocoa, two grains before meals, or 10 to 20, or even 30, grains of bismuth subnitrate before eating, proves a great relief. -WM. WORMLEY.

Gastric Ulcer.-In gastric ulcer (acute or chronic) the patient should drink before meals a tumblerful of ozonized water (made of one ounce of hydrozone and two quarts of water), and after meals he should take at least two teaspoonfuls of glycozone in a wine glass of water. This is the plan of treatment, and it should be persisted in for such a length of time as is necessary to heal the gastric ulcer.

-R. C. KENNER, St. Louis Medical and Surgical Journal, May, 1902.

Cerebral Hemorrhage.-Wm. Browning (N. Y. Medical Journal, February 15, 1902) cautions against the use of stimulants, saline injections, depressant diaphoretics, opiates, digitalis, nitrites, and muscular exertion.

Apomorphine as an Hypnotic.-Coleman and Park state that the drug should be given hypodermatically, beginning with gr. 3, and to increase slightly in a short time.

The Principles of Rhinological Practice. The views of E. Pynchon are summarized in the following propositions: (1) In the normal nose the nostrils should be of equal caliber and should jointly have a sufficient capacity to at all times supply the requirements of easy nasal respiration. (2) In the ideal nose the walls of the septum are practically plane, and are at no time or place touched by the tissues of the outer wall, in either passage, and, furthermore, no points of contact exist elsewhere therein, so as to interfere with either ventilation or drainage, or prevent the normal evaporation of nasal moisture. (3) While in an ideal nose the septum is vertical and nearly plane, a moderate irregularity thereof will not impair the nasal respiratory functions, provided there are no points of contact or abrupt elevations therein, and the lumen at all points is sufficient. (4) Abnormal redness of the nasal mucous membrane is an unfailing sign of irritation, the cause of which is generally of a structural nature, and, therefore, amenable to surgical treatment. (5) The indications for operative interference depend upon both the subjective and objective symptoms. A noticeable inadequacy of either nasal passage, the presence of excessive or retained secretions, or an abnormal redness of the mucous membrane at any point, are all evidences of abnormality, which, if coupled with inconvenience to the patient, invite corrective attention. (6) In the treatment of chronic hypertrophic nasal troubles, the indication is to remove all obstructive, redundant, or pathologic tissues, and at all times the chief indication is to cause the defective nose to conform as nearly as practical to the contour and character of the ideal standard.-Laryngoscope.

Vol. 64, No. 7. Whole No. 1710.

Original Articles.

CONSIDERATION OF MAMMARY CYSTS IN THE DIFFERENTIATION OF BREAST TUMORS.

BY ROBERT ABBE, M.D.,

NEW YORK CITY.

To the lay mind every tumor of the breast is a malignant one. To the physician there are several varieties, the differentiation of which is as important to him as to his patient. There are gross appearances by which one may readily diagnose advanced malignant tumors, but in their incipiency there is so close a resemblance between various kinds that an innocent growth may be readily mistaken for a malignant one.

There are several reasons why I speak of mammary cysts with emphasis:

1. Because they are much more common than is generally thought.

2. Because in every instance in which these cases were referred to me, they were sent by the physician believing the tumor to be a malignant one, and in each instance the patient expected to lose the breast.

3. Because many physicians and surgeons advise removal of the entire breast even when recognizing the nature of the cystic disease, arguing that if left the gland is liable to undergo malignant degeneration.

As regards the relative frequency of cysts and other mammary tumors, I have been impressed by the records of my own private office work. In former years it was my own custom to regard mammary'cysts as degenerative and frequently to remove the gland, but during the last eight or ten years I have invariably tested the nature of the tumor by aspiration before allowing myself to make an absolute diagnosis, because of the great similarity in the feel between deep cysts and deep solid tumors on palpation.

In recounting, therefore, my private office notes, disregarding all hospital work, I find that during eight years I have seen forty-one cases of mammary cysts, and fifty-six cases of scirrhous tumors, besides a number of innocent inflammatory adenomas. This should represent not far from the average experience of surgeons in a corresponding number of cases, inasmuch as the patients were referred to me, or came voluntarily without the slightest chance of selection.

On observation based on this series of cases I call attention to two points that have impressed me: 1. The differential diagnosis, which can be said to be easy and absolute.

2. The cure, which can also be said to be easy and absolute.

I have habitually made diagrams of the localization of the cysts and solid tumors of the breast, from which I have made the charts shown on p. 242.

It is of great interest to note from these that while cysts may be localized in any part of the gland, with a slight predominance only in the upper

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and outer segment, the scirrhous tumors are almost universally distributed between the nipple and the axilla.

In speaking of the hard tumors, I have excluded adenomas and small sarcomata, as well as mammary induration following old abscess change. Relatively in two breasts both the cysts and the scirrhous tumors appear in almost exactly equal number in the right and left, so that one can say that there is no greater probability of causation from injury to the right or left; but incidentally the localization of the scirrhous tumor on the axillary side of the nipple implies a progressive advancing absorption of some infective cause having entrance at the nipple and advancing along the line of main lymphatic currents.

Cysts, on the other hand, are localized in any part of the gland, and being due to the well recognized cause of fibroid thickening of the galactiferous ducts, with stenosis and retention of duct secretion, they are found in the lower as well as the upper segments, the inner as well as the outer. A tumor in the lower half, therefore, has the greater probability of being a cyst.

Of the forty-one cases of mammary cysts, threefourths were single cysts, and in one-fourth, two or three, or even four were found. Thirty-three out of forty-one patients were between forty and fifty years of age, the others were over thirty-five years, excepting in two instances. This tendency to fibroid changes occurring during the atrophy of the climacteric has been noted by other observers.

The contents of the cysts varied in quantity from one drachm to one ounce, and the fluid drawn was usually opalescent, whitish and turbid, the deposit on standing, showing a considerable amount. of granular fat, a few leucocytes and many small and large round mononuclear cells, whose protoplasm has undergone fatty degeneration.

a

The cyst wall is usually so attenuated as to be imperceptible on palpation when the cyst is emptied. In two instances one or two papillomatous ingrowths were found. In one case, woman of twenty-one, four such cysts contained more characteristic milk products; the typical galactocele showed activity of the mammary glands; this cannot, however, be regarded in any sense as different from the type appearing in later life, and proved equally curable by aspiration; several years having gone by and the patient is known to have had no return.

The gross characteristics of these tumors, then, for diagnosis may be said to be a hard tumor of any section of the gland, usually placed rather deeply, never dimpling the skin like a scirrhous one or drawing on the nipple; sometimes quite a flat ovoid; and in the majority of cases not giving a distinct sense of fluctuation on palpation.

It is this deceptive hardness to which I draw special attention because in many cases it is impossible to detect the cystic nature without the use of the aspirator needle; hence the physician should always be ready to pierce every doubtful tumor with a small, sharp aspirating needle, attached to a syringe holding perhaps two drachms, in order to

PROSTATIC HYPERTROPHY AND ITS

RADICAL CURE.

BY WILLIAM POST HERRICK,

NEW YORK.

IN no branch of surgery has recent progress been so great. From hazardous operations of doubtful efficacy, or palliative measures of still more dubious worth, we are emerging into more uniform methods, and an operation which is serious, but when undertaken at a proper time, is giving very definite results. Our responsibility is thus enhanced, and the commonness of the affection, every third man having, when aged, an enlarged prostate, and every eighth one which gives symptoms, lends it an almost personal interest. (Sir H. Thompson.) Moreover, the very wealth of our literature makes it confusing and a review of salient facts of value.

The disease is one of obstruction, and as mechanical and surgical means must be used for its relief, first briefly to recall its surgical anatomy may not be amiss.

1. The prostate is comparable in size and shape to a French chestnut, measuring transversely about one and one-half inches (or 36 mm.) near the base, about one and one-quarter inches (or 30 mm.) in length, about three-quarters of an inch (or 18 mm.) in thickness, and weighs from four and one-half to four and three-quarters drachms (16 to 20 gms.) It is a firm glandular and muscular body. The glandular substance is spongy and yielding, its color reddish gray; it consists of numerous tubular alveoli which unite into a similar number of excretory ducts, emptying into the prostatic urethra. It is associated with a large quantity of plain muscular tissue which forms the principle stroma of the organ. The different portions of the gland are united by areolar tissue and supported by processes of the deep layer of the fibrous capsule and by the muscular stroma. (Quain and Grey.) This normal size, consistency, and structure of the prostate are important in estimating the amount and character of the hypertrophy.

2. "The fibrous capsule, which includes much plain muscular tissue, is divided into two layers, between which the prostatic plexus of veins is inclosed." (Adams.) A true capsule has been described and is often seen as a glistening membrane surrounding the gland in hypertrophy. This is important, as the fibrous capsule also is generally much more distinct and the veins between its layers larger in hypertrophy. In operation it should therefore be respected and the gland shelled out of its fibrous capsule (following the line of cleavage between it and the true capsule), leaving if necessary some of the muscular tissue, as tearing the fibrous capsule gives more hemorrhage and extracapsular dissection is much more difficult.

3. "The prostate is usually described as consisting of three lobes. The lateral lobes form the great mass of the gland and are united with one another in front of the urethra and also behind the urethra below the ejaculatory ducts. The middle lobe, claimed by some to be merely pathological, lies behind the upper portion of the urethra, below the apical portion of the trigone of the bladder and above the common ejaculatory ducts; at the sides it passes without any line of demarcation into the lateral lobes." (Quain.) J. Griffiths finds the middle lobe with its own glandular tissue and ducts distinct in about one in ten cases of the young, an interesting coincidence in proportion to those giving pathological symptoms. "The urethra passes through the prostate from its base to its apex in the median plane about one-quarter of an inch from the anterior surface and nearly one-half inch

from the posterior. The two common ejaculatory ducts enter at a median depression situated at the upper part of the posterior surface, and passing downward and forward in close contact with one another, open on the posterior wall of the prostatic portion of the urethra." (Quain.)

A regard for the lobular arrangement helps us in estimating the real amount of obstruction present, as there may be severe obstruction with little hypertrophy where we may know that the middle lobe is mainly involved. Also in intracapsular excision it aids in respecting the urethra and some claim the ejaculatory ducts, and in some cases the prostate has been removed without opening the urethra.

4. The Relations of the Prostate.-"The base of the prostate is situated immediately below the neck of the bladder, the apex above the superior layer of the triangular ligament. Its posterior surface, which is flat and larger than the anterior, lies against the second part of the rectum, so that it can readily be felt by passing the finger in that organ. The anterior surface is convex and is placed about onehalf inch behind the pubic symphysis. (Quain.) Its base is beneath and its apex beyond the neck of the bladder. To reach it from above, then, we must pass through the summit and base, tearing the prostate up from beneath the neck of the bladder, whose circular fibers largely maintain urinary control, and when torn or greatly stretched generally result in incontinence. We must work at a great depth, where it is often hard to see, with hemorrhage hard to prevent by resecting the capsule, difficult to control, and we leave a raw dead space communicating with the bladder and urine, which is often infected, and drain this up hill unless the patient is subjected to the additional operation of perineak drainage. “On the other hand, the prostate is readily felt from the rectum," one of the greatest aids in diagnosis and showing its accessibility from the perineum. The perineal, then, is the direct route to the prostate.

5. "The prostate is held in position by the posterior ligaments of the bladder, by the fascial continuation of its fibrous capsule and the anterior portion of the levator ani muscle. It has been noted that pressure from a full bladder diminishes the anteroposterior diameter of the prostate and increases the lateral." (Grey.) When in its capsule, then, diffused pressure from the bladder will tend to fix the prostate, and the capsule being opened to depress it and aid in separating it from the capsule while compressing the prostatic sinuses.

6. It is now agreed that the physiological function of the prostate is almost entirely genital, secreting a fluid to mix with the spermatozoa and fluid excreted by the vasa deferentia and seminal vesicles, in the prostatic urethra; in opening the ejaculatory ducts and ejaculating the semen and possibly simultaneously blocking the entrance to the bladder. The former idea that the prostate greatly aided in control of the bladder is given up, as in eunuchs with atrophied prostates, or in children in whom they are not developed, and in women in whom they are absent, urinary control is not interfered with, and now this is borne out, as with many cases of complete prostatectomy incontinence is the rare exception (e.g. Syms twenty-three cases, only one partial loss of control of the bladder).

II. A few words concerning the cause and character of prostatic hypertrophy.

(1) The etiology has not been demonstrated. (a) Of the predisposing causes age is the most important; it is rarely developed before forty-five