In looking at the photograph the superficial veins can be plainly seen. Taking this fact into consideration, might it not be worthy of a trial early in the progress of a similar case to dissect up the skin, and then replace it in its former position, hoping to change the abnormal nutrition and cause a shrinkage of the organ by breaking up its blood supply, without which it could not so lustily thrive?

She experienced a somewhat tardy healing, partly I think on account of the irritating and septic fluid, which was considerable from the gland, and partly due to the want of sufficient circulation in the skin flaps after having been torn from the adherent organ.

No. 2.-Microscopical appearance of Tumor. 350 diameters. A.-Acini nearly normal, but dilated. B. M.-Basal membrane. g. c.-Gland cells, margins of which are undefined protoplasm and nuclei granular. . c.-Cells lying in lumen, result of proliferating activity of g. c. A.-Acini disarranged by pressure of connective tussue. c. t.-Connective tissue, split, cloudy, degenerated, strictly diagramatic. c. t. n.-Connective tissue nuclei.

Notwithstanding we left an excess of two inches of flap, there was a contraction in healing until it barely covered the wound.

The right gland was amputated September 13th, and weighed 13 pounds. The left was removed October 2nd, and weighed 11 pounds. Two weeks later she returned home in good health, and has remained so.

Dr. Wm. Krause of this city has kindly prepared a report of microscopical appearance of these organs, which is the most interesting part of the case, and reads as follows:

Dr. T. J. Crofford, City.

The tumor sent me for examination is one of those rapidly growing, circumscribed, benign neoplasms which have been variously styled diffuse adenoma, acute fibro-adenoma, acute diffuse hypertrophy, &c.

Microscopically, it appears like a fatty tumor, doughy to the touch but rather more nodular, with firm centres. On section it looks white, with very few vascular spots, soft in portions. The exuding juice consists of fatty and granular cells. Some portions are firm like collections of fibromate. Near the base of the tumor and a little to one side, a pink mass the size of a walnut was found, differing from all the balance of the growth, both in gross and microscopic appearance.

Under a low power the tumor is seen to consist mostly of fibrous stroma without fatty tissue, the gland tissue being in places normal, but every where pervaded by the growing fibrous matrix, showing every gradation from simple increase of stroma to complete destruction of gland, loose epithelial cells being imprisoned like in a very firm scirrhus. For the most part it looks like fibro-adenoma, the cells lying in open spaces, often arranged in concentric layers, surrounded by a wall of firm, fibrous tis

sue.

Under a high power the connective tissue can be seen to split roughly, the bundles interlacing, hy-a-line or cloudy, with very few neuclei. The acini are in some places nearly normal, though apparently dilated and filled with deeply staining cells arranged in one or more layers. Numerous lymph channels pervade the mass, and here the process of formative tissue generation can be seen in all stages-escaping corpuscles undergoing mycosis,

young connective tissue cells in the act of growing and elongating, &c.

Osmic acid preparations show a few minute fat globules scattered through all the tissues.

The macroscopically pink portion differs from the main mass, principally in not having any normal gland tissue in it; the acini are only masses of highly staining cells without any effort at arrangement. The stroma is characterized by having a large number of nuclei, the connective tissue being embryonic in appearance; a few nuclei give the impression of being those of unstriated muscle, particularly around the epithelial collections which take the place of acini.

In the place of duct lumina there are open spaces in the spindle-celled stroma, filled with the same dark, staining cells found in the more normal acini and ducts.

We thus have a rapid growth, simulating cancer, adenoma, fibroma and hypertrophy, but yet not corresponding entirely to any of these.

The points of difference between this and the one described by Billroth in one of his two cases, are the entire absence of glandular activity beyond the proliferation resulting from direct pressure, and the relatively smaller amount of normal gland tissue. We have in the pink portion described above very probably one of the "sarcomatous nodules" spoken of by Billroth in his case. Billroth's description coincides with this more than the diagram given, for in no portion of this growth are the acini so abundant, and I doubt if physiological activity were possible to any extent in this case-certainly not an increased one-without which there can be no true hypertrophy. Acute diffuse hypertrophy is no doubt a good name clinically, but histologically we have every evidence of primary hyperinosis without any signs of irritationround cell infiltration, the gland cell proliferation being secondary.

The extreme coarseness and interlacement of the fibrous tissue stamps it as a neoplasm.

The most remarkable point in the histology of these tumors is

that they are in every respect diffuse as far as the mamma is concerned, but do not invade the surrounding tissues.

Very respectfully,

WM. KRAUSE, M.D.

SOME PRACTICAL POINTS IN ABDOMINAL
SURGERY.*

BY JOHN H. M'INTYRE, A.M., M.D, ST. LOUIS, MO.

"Suppose I give a hint to you,

Suppose you give a point to me;
Then I shall give a hint to you,

And you will give a point to me "

in the discussion which I hope will follow the reading of this paper.

In my opinion, any "point" or suggestion which diminishes the risk to life after laparotomy is an important one.

The first point to which I call your attention is that of anæsthetics, the safest and best of which is bichloride of methylene used in Junker's inhaler. I have used it in laparotomy work for the past ten years without a single untoward symptom, and with the greatest satisfaction, and upon many occasions have put it to as severe a test as it is possible to put an anæsthetic.

By its use anesthesia can not only be promptly induced, but safely maintained for any desirable length of time, and it is rarely followed by nausea and vomiting.

By the use of the inhaler of Junker, overdosing is next to impossible—in reality the patient takes inspired air, charged with the vapor of bichloride of methylene, and it is surprising what a small quantity is required in doing a prolonged opera

tion.

Short incisions constitute another point of excellence, and should never be extended beyond the point of necessity in removing a growth of given size without bruising the tissues. In removing the ovaries or fallopian tubes, or both, it is rarely that the ventral incision need be over two inches in extent.

*Read before the State Medical Association of Missouri, Excelsior Springs, Mo., May 21, 1891.

In dealing with adhesions, perseverance by well directed effort will always succeed; remembering, however, that violence is always harmful, and the necessary force should be that of gentle

momentum.

Intestinal adhesions should be separated as far from the gut as possible, for by so doing the danger of hemorrhage is much lessened; they should be carefully examined afterward, as the placing of a Lembert suture in the proper place at the opportune moment will prevent the mortification of a future fecal fistula.

In the management of the pedicle, I always use Japanese cable silk, transfixing and tying the ordinary surgical knot when dealing with large tumors; for removal of the appendages I am partial to the Staffordshire knot of Tait.

DRAINAGE.

"When in doubt " I always drain, and prefer the Keith tube to all others, and am a thorough believer in flushing the abdomen. with a large quantity of hot distilled water; it is marvelous sometimes to see how many blood clots can thus be washed out, even after careful sponging, besides it is one of the best methods of relieving shock.

Closure of ventral wound can best be done with silk worm gut; it is the ideal suture, as it is round, smooth and very strong, and can be rendered perfectly aseptic. As it is rather stiff, it should be steeped for a few hours before using in a solution of some kind so that it can be tied tightly. It should be threaded at each end upon straight or slightly curved veterinary needles. The needle, being held in the grasp of the SpencerWells needle holder, should be passed from within outward, always including the peritoneum. Sutures should be placed five or six to the inch. The frequent cause of ventral hernia following abdominal section is an insufficient number of sutures.

AFTER MANAGEMENT.

For the first twenty-four hours nothing should be taken into the stomach, except a little hot water; bits of ice chewed or swallowed do not relieve thirst.

The second day a little barley

water may be allowed, and on the third day she can be promoted