ŒSTRIN TREATMENT OF CYSTIC DISEASE OF THE BREAST

1294 work. His cases have been accurately documented in pursuance of a far-sighted design, and the records are available in the Brain Tumour Registry at New Haven for such examinations as the future may indicate to be desirable. It is to be hoped that further inquiries of this nature may be made by others of Dr. Cushing’s former assistants, so that before many years there will be added to the initial studies of van Wagenen and myself a greater and statistically more significant volume of knowledge on the late results of treatment of intracranial tumours. That such unrestricted studies of one man’s work by his pupils are possible indicates to some extent the sense of partnership with which Dr. Cushing has invested his clinic, a quality that is the mark of all great teachers.

epochal

BIBLIOGRAPHY 12. Gowers, W.: A Manual of Diseases of the Nervous System, London, 1893, 2nd ed., vol. ii., p. 526. 13. Horrax, G., and Putnam, T.: Brain, 1932, lv., 499. 14. Lane-Claypon, J.: A Report on the Late Results of Operation for Cancer of the Breast, Rep. Pub. Health and Med. Subjects, No. 51, London, 1928. 15. Lane-Claypon, J., and McCullagh, W.: A Report on the Treatment of Cancer of the Uterus at the Samaritan Free Hospital, Rep. Pub. Health and Med. Subjects, No. 47, London, 1927. 16. Meagher, R., and Eisenhardt, L.: Ann. of Surg., 1931, xciii., 132. 17. Oldberg, E.: Jour. Amer. Med. Assoc., 1933, ci., 1458. 18. Olivecrona, H.: Arch. f. klin. Chir., 1934, clxxx., 445. 19. Starr, M.: Organic and Functional Nervous Diseases, 1st ed. London, 1903. 20. Tooth, H.: Brain, 1912, xxxv., 61. 21. Tooth, H.: Seventeenth Internat. Cong. of Med., London, 1913, Section VII., Part 1, London, 1913, p. 203. 22. van Wagenen, W.: Arch. Neurol. and Psychiat., 1927, xvii., 57. 23. van Wagenen, W.: Jour. Amer. Med. Assoc., 1934, cii., 1454.

ŒSTRIN TREATMENT OF CYSTIC DISEASE OF THE BREAST BY E.

DAHL-IVERSEN, M.D.

PROFESSOR OF SURGERY IN THE UNIVERSITY OF COPENHAGEN

management of cystic masto basis in recent observations on the favourable influence of cestrin. Under this treatment the symptoms either disappear or are considerably relieved, and examination shows that the signs are diminished or almost absent, the results being especially good in early cases. The brownish or greenish discharge becomes serous and either decreases or stops. Cutler, Gabrielianz,2 and Taylor 3 have reported equally satisfactory experience of the cestrin treatment of mazoplasia and mastodynia. During the year 1935 we have treated 22 cases of cystic mastopathia with oestrin and have obtained considerable recovery in 18. In 2 patients, both between twenty and thirty, the local and general condition was aggravated; and in 2 cases there was no effect. In older persons-i.e., in the middle forties-oestrin treatment will sometimes do harm, presumably because the patient, just before the menopause, is already suffering from a relative excess of oestrin ; and the worsening of the general condition of the two patients under thirty resembled that usually observed in the middle forties, with flushes, sweating, anxiety, and especially dizziness. In the light of our present experience we should advise a dosage of 2000-4000 mouse-units daily THE conservative

pathia finds

a new

1 Cutler, M.: Jour. Amer. Med. Assoc., 1931, xcvi., 1932, xcix., 2152 ; 1933, ci., 1217, Ann. of Surg., 1931, 223. Surg., Gyn., and Obst., 1929, xlviii., 463. Amer. Obst. and Gyn., 1933, xxv., 504. 2 Gabrielianz, A. G.: Amer. Jour. Obst. and Gyn.,

499. xxv., 3

1201 ; xciii., Jour.

1933,

Taylor, H. C., Jr.: Arch. of Surg., 1930, xxi., 42 ; Surg., Gyn., and Obst., 1933, lvii., 627.

by mouth or 10,000-20,000 m.u. once a week intra. gluteally. The course of treatment should last

some cases should be continued with pauses. The idea that the remedy is more than symptomatic is supported by the evidence of biopsy in the case described below. The treatment seems applicable especially to cystic mastopathia in young women, in the hope of avoiding operation. Surgery should be regarded as inadvisable unless cestrin proves of no avail or there is some doubtful change in the clinical picture. On the other hand, the conservative treatment necessitates close and continuous observation of the patient. The affected breast should be supported but on no account

3-6 months and in

longer,

compressed. try conservative treatment in older but if it does not help we have less dispersons, inclination to operate, particularly if there is any suspicion of papillomata in the lactic ducts, or of early carcinoma. With older patients conservative treatment demands even closer and more continuous supervision. If operation is decided upon partial extirpation finds favour if the process is clinically localised ; for experience shows that as a rule the condition does not recur, for many years at least. But partial operation likewise carries the necessity for careful observation. Where the changes are diffuse, partial extirpation is of course unwise and the best We

also

is ablatio mammae, with possible retention of skin, areola, and papilla. Whatever operation is adopted microscopical examination is essential, so

plan

that a radical removal may be performed if need be. As an example of considerable recovery after cestrin treatment the following case may be quoted. The patient was 49 and had had two children, the second being 15 years old. The menopause had taken place nearly eight years ago, menstruation having previously been normal. On and off for the past two years she had had stabbing pains in both breasts, and had been able to squeeze a dark, greenish, slimy liquid out of the papillae. Examination three months ago showed that the whole right breast was of firmer consistency than is normal, and full of numerous small lumps. A greenish, slimy liquid could be pressed out of the papillae from all quadrants. In the left breast there were corresponding changes in the two upper quadrants, and the process also extended a little way down into the two lower ones. The same sort of secretion as in the right breast could be pressed out of the papillae from the affected regions. Both breasts were slightly tender. The axillary glands were not swollen. Examination of the internal genital organs revealed no abnormalities. After the patient had taken 86,000 m.u. of oestrin by mouth (3000 daily) there was considerable improvement. The stabbing pains were now less frequent and compara. tively slight. The affected parts of the corpora manomse were softer and less tender, the small lumps were either not palpable, or only to be felt indistinctly in a few places; The discharge, which was now nearly serous, could be pressed out of only a few lactic ducts. In a limited region in the upper lateral quadrant of the left breast, however, the improvement was less pronounced than in the other parts, and in view of the patient’s age a portion was excised under local anaesthesia. The histological picture was not characteristic, being suggestive of the regressive processes seen in a breast that has been subjected to energetic X ray treatment, or simply those observed at the menopause. There was a cellular reaction round the lactic ducts and this, in association with the characteristic pale epithelium and the presence of numerous glandular tubes without corresponding acini, speaks of regressive changes. The breast had evidently been the seat of abnormal development of the glandular tubes such as we see in benign cystic disease. There was no indication of malignancy. We continued the oaatrin, this time as a weekly dose of 20,000 m.u. intergluteally. After another 100,000 m.u.

1295 had been given in this way we stopped the treatment and found both breasts soft, of almost normal consistency. The small lumps were no longer palpable. When the right breast was squeezed hard it was possible to press a little greenish discharge out of one of the lactic ducts, and from another one a little serous fluid. In the left breast a little serous liquid could be obtained from a single lactic duct, but only after firm pressure. The tenderness had disappeared. Eight months after ending the cestrin treatment the condition remains the same.

It will be observed that in this case of bilateral cystic mastopathia excellent results followed administration of cestrin (86,000 m.u. by mouth and 100,000 by injection). As already stated we are able to record a considerable degree of improvement in 18 of 22 cases in which cestrin has been used.

THE EVIDENCE OF A BULLET WOUND SELF-DEFENCE OR MURDER ?

he fired. He estimated that the distance from the muzzle of his rifle to L.’s head would be three or four feet. He said that L. fell straight backwards on to the floor, where he was found on his back with his feet towards Z. and that he did not move or utter a sound. When the police arrived they found Z. standing at the point marked z ; Mrs. Z. in the bedroom quietening the three boys ; and the body stretched out as described. Around the right side of the head there was a rather large pool of blood which was virtually part of a pool of blood and brain matter on the table (see Figure). At a point so

marked B,

______

BY G. R.

OSBORN, M.B. Melb.

near

door, found

Jugo-Slav employed as a miner on the Kalgoorlie goldfields ; he is happily married and has three small sons. L. was a Montenegrin, also a miner, and the two men were formerly good friends. The friendship broke off when L.’s infatuation for Mrs. Z. became obvious, and he keep away from the house.

was

warned to

A few days before the shooting he sent a message to Mrs. Z. saying that he would go to see her at 9 P.M. on Monday (at a time when Z. would be at work in the mine). Mrs. Z. gave the message to her husband, who decided, he said, to give L. a bad fright. He borrowed a 0-44 Winchester rifle from his butcher, " to shoot a mad cat " and bought a few bullets from the local store. These bullets are made of lead without a hard jacket and carry a heavy charge of black powder ; they are of the type He took the rifle home and used for shooting kangaroos. hid it under a bed in the front bedroom. He took no lawful steps to have L. restrained. On the Monday afternoon Z. went to work as usual, but at 8 P.M. he pretended he was ill, was brought to the surface and went home. Reference to the plan of his house (Fig. 1) is necessary to follow the events which then took place. He found his wife sitting (at the place marked Zl) sewing in the living-room by a long table. He told her not to worry and went into the front bedroom where his boys were sleeping. He then loaded the rifle and waited in the dark for the arrival of L. At the appointed time L. entered by the back door and walked up to the spot marked L beside Mrs. Z. He put his arms around her and started

making love to her. When Z. heard this he rushed out of the bedroom to the spot z, and, holding the rifle with the butt under his elbow and the barrel pointing upwards, called out " Hands up, hands up ! " L. was then shot dead. Z. did not move from the point z, and was still there when his brother-in-law returned with the police. Z.’s story of the out to L. the latter

shooting was that when he called lunged at him with his right hand while thrusting his left towards an inside coat pocketa movement which Z. decided was to get a revolver. the found a loaded revolver Actually police fully in this pocket. Z. said that he then realised that if he did not shoot he would himself be killed, and

a

of bullet, which had

evidently had

no

velocity when

THE STORY a

was

fragment

THE deductions drawn from injuries caused by bullets may be of great importance in the law courts, and medical men who may have to give evidence about such injuries should be familiar with their characteristics. This was brought home to me by the following case.

Z. is

the

kitchen

FORMERLY MEDICAL OFFICER IN CHARGE OF THE COMMONWEALTH HEALTH LABORATORY AT KALGOORLIE, AUSTRALIA

FIG. l.-Diagram of scene of shooting. z marks position of Z. when shooting L. z’ shows position of Mrs. Z. and L that of L. beside her. B shows where a fragment of the bullet was found, and A shows theoretical position if victim was shot from behind. The position of the body and blood stains on the table are

it

reached this spot, for there were

no

marks on soft the indicated. wall. The walls were of paper over hessian, and it would not be possible for the bullet to rebound from them. THE

POST-MORTEM FINDINGS AND THE DRAWN FROM THEM

CONCLUSIONS

On post-mortem examination a large gaping wound found just behind external angle of the right eye, about 2 in. in diameter (Fig. 2). There was no bone in this hole and the brain substance, much macerated, could be seen through it. Behind this wound and immediately above the right ear was another hole, which was not ragged, but clean-cut ; it admitted only the little finger and also communicated into the brain substance. No scorching or blackening was detected. On dissection the bones of the skull were found to be extensively fractured on the right side. The brain substance was also macerated very extensively on the right side and much of it was missing. In its substance

was

many fragments of small bone, and two pellets of lead were extracted. From these findings the examiner drew the following conclusions :-

were

It is my opinion that the damage was caused primarily by a leaden bullet which had entered the head through a clean, well-defined hole above the right ear, smashing the bone there in radiating fraotures, entering the brain substance, part of it remaining, and another portion escaping through the ragged tear in the soft tissues at the outer corner of the orbital cavity and that instantaneous death

was

the result.

This conclusion was presumably based on the belief, which is widely held, that bullets make a small wound on entry and a large one on exit. It gave