ORIGINAL LE(/DURES- 
TUMOR OF THE MALE BREAST 
AND 
CYST OF THE NECK, 
By J. H. POOLEY. M.D., 
Professor of Surgery, Sfarlfn'g Medical College. 
[REPRINTED FROM THE OHIO MEDICAL AND SURGICAL JOURNAL.] 
COLUMBUS: 
NEVINS & MYERS, BOOK AND JOB PRINTERS. 
1878. ORIGINAL LECTURES 
Clinical Lectures on Surgery Delivered at Starling Medical 
College, Columbus, 0., By J. H. Pooley, M.D., Prof, oe Surgery. 
LECTURE III. 
The patient I now present to yon, for the last time, is one 
whose case, no doubt, you all remember, but as I wish to 
make it the subject of somewhat extended remarks, I will 
briefly recapitulate the main facts in connection with it. 
Michael Burke, forty-five years of age, a native of Ireland, 
and a laborer in a rolling mill, came before us two weeks 
ago on account of a tumor which had developed itself in his 
right breast. 
He is a perfectly healthy, and very robust and muscular 
man. Seven or eight months ago he noticed the tumor for 
the first time, since when it grew steadily, and rather rapidly, 
up to the time of our first seeing him. On that occasion we 
found the situation of the right breast occupied by a tumor, 
as large as the largest-sized hen’s egg, but not of that shape, 
having rather the form of a normally developed mamma of 
a young girl at puberty. It was hard and firm, quite so, but 
not stony-hard, like scirrhus. It was freely movable over the 
pectoral muscle; the skin over it was unattached, except 
just at the nipple. It was not, and never had been painful, 
but the fact of its existence annoyed him. He had got into 
the habit of frequently handling it, watching its growth, 
and worrying over it, and was anxious to have it removed 
He said he had never received any blow or injury in that 
region, neither was it habitually pressed upon in his usual 
Tumor of the Male Breast—Cyst of the Neele. 2 
occupation; he could think of no reason for the appearance 
of the tumor ; he had never heard of any cancer or tumors 
in any of his relations. The opinion was expressed that the 
tumor was benign in character, probably either a fibroma, or 
a firm lipoma, but we declined to venture upon an absolute 
diagnosis until after its removal. This was done by an 
operation exactly similar to that for removal of the female 
breast, and which I need not say anything about—one liga- 
ture was applied to an artery that bled rather persistently 
after the oozing had stopped, the wound was washed out with 
a solution of carbolic acid, one drachm to the pint of water, 
closed acurately, with numerous points of fine suture, and a 
compress and firm bandage applied. 
More than half of it healed at once, by first intention; 
the rest is now, as you see, well, and to-day he leaves the 
hospital. 
After the removal of the tumor, we made a section of it 
in your presence, and even then were unable to determine 
its character, but could only say again it was either a fibrous 
tumor, or a very firm lipoma, with a leaning toward the lat- 
ter opinion. We have now the results of a careful examina- 
tion made by Dr. Frankenberg, our Professor of Pathological 
Anatomy. 
The Professor says : “ Microscopical examination of the 
tumor removed from Michael Burke, and referred to me for 
examination, shows that its elements are fibrous tissue in 
abundance, fat cells containing oil, and occasionally a col- 
lection of small cells, some of which are of an irregular 
shape, others round. The fat cells are arranged in layers 
extending through an entire section, and separating the 
fibrous tissue or stroma, but there seems to be no regularity 
in the arrangement of these fat layers, but whenever they 
are found they are somewhat extensive. Cavities are also 
found which resemble those of acini found in the gland tissue 
of the breast, lined with epithelial cells. The small cells 3 
spoken of above are grouped together in masses varying in 
size ; they appear to be lencocytes with granular matter.” 
From this description, it appears that our tumor was an 
unusually firm lipoma, that, is, one with unusual develop- 
ment of fibrous tissue or stroma developed in the rudiment- 
ary gland tissue of the male breast, and probably by its 
presence and growth provoking some hypertrophy of that 
tissue. 
Now, gentlemen, this is a very interesting case—interest- 
ing from its rarity, for all tumors—all diseases of the male 
breast—are more or less rare. To show you how rarely tumors 
are met with in the male in this region, I may mention that 
Dr. John Chiene has collected, in an article in the Edinburgh 
Medical Journal, for July, 1871, all the cases of tumors of 
the breast admitted into the Edinburgh Royal Infirmary, 
under Mr. Syme’s care, during a period of thirty-six years, 
from 1833 to 1869, and from this record it appears that in a 
total of 247 cases only two were in the male. One of these 
was a fibrous tumor, removed with successful result; the 
other a scirrhus tumor, which returned in loco in a year. 
Very few men have ever had such a clinical experience as 
this of Mr. Syme, and if he found only two tumors of the 
male breast, we may conclude that they are rare enough to 
be of interest. 
Dr. John C. Warren, of Boston, whose field was extensive 
and his experience enormous, and who wrote a work on 
tumors, only refers to two cases of tumor of the male breast, 
and Dr. J. Mason Warren, in his work entitled “Surgical 
Cases and Observations,” only mentions one case of the kind. 
You find very little information—indeed, I might say none 
at all—in the ordinary text-books of surgery on the subject 
of diseases of the male breast, and not much more in the 
special works of Velpeau, Birkett, and Astley Cooper. 
Such being the case, and our attention being called to it 
by the patient before us, perhaps it will be both interesting 4 
and profitable for us to spend some little time upon the 
subject. 
This rarity of disease in the male breast is owing, of 
course, to its small and undeveloped state, and absence of 
function, the general rule being, that organs of the most 
perfect development and greatest functional activity, are 
most subject to disease. Hence, the great liability of the 
female breast to various forms of inflammation, tumor, and 
cancer. Generally speaking, the male breast is in so rudi- 
mentary a condition as to escape recognition altogether, the 
mammilla and its surrounding areola alone marking the site 
of the organ. But, however small and undeveloped, the rudi- 
ments of a gland do exist, and in certain exceptional cases, 
and in some instances of disease, become quite conspicuously 
developed. 
All authors on the subject mention individuals of the 
male sex in whom the mammary development has been re- 
markably full, though many of these have no doubt been 
mere local development op adipose tissue, or at least princi- 
pally such. 
Sir Astley Cooper gives a detailed account of a young man 
whose breasts were unusually developed, and remarks that 
he was of a slender and effeminate form, and that his testi- 
cles were remarkably small, and hints his belief that this 
will generally be found the case in such instances. 
Not only has large size of the gland sometimes been no- 
ticed in masculine subjects, but true functional activity or 
secretion of milk has been observed in quite a number of 
authentic and undoubted instances. Dr. Young communi- 
cated one case to Sir Astley Cooper, and Humboldt, Franklin, 
Dunglison, Blumenbach, and others relate cases. The fullest 
account of this kind that I know of is one by Dr. Schmetzer, 
of Ileilbronne, in Schmidt’s Jahrbucher, for 1837, and quoted 
in the American edition of “Cooper on the Breast.” The 
subject of it was a sanguine, robust soldier, twenty-two 5 
years old. When eighteen years old he often felt a pricking 
sensation in his breasts, and slight periodical colic. About 
a year later, after each occurrence of such symptoms, a slight 
swelling of, and milky discharge from the mammae; and 
during work, his shirt was several times a week wetted with 
it. When in the hospital for acute rheumatism a consid- 
erable quantity of milk was found to oe secreted. On exam- 
ining the breast and nipples, the latter were found highly 
red, erectile, and somewhat cracked at their apices, and much 
higher than in men generally, and surrounded by a some- 
what darker areola, through which a subjacent, vascular 
network could be seen. On pressing the papilse, two or 
three fine streams of milk would jet out of minute orifices; 
it had a bluish-white color, and a very sweet taste. The se- 
cretion wras constant, but increased at various periods, es- 
pecially at night, producing a somewhat painful sensation 
until it was evacuated. The usual quantity was from half 
an ounce to an ounce daily, but sometimes not more than 
two or three drachms. On one occasion a wineglassful was 
drawn off, and in the fortnight that he was under observa- 
tion, ten or eleven ounces were secreted. After the evacua- 
tion of it, he said he always had headaches, faintness, and 
sometimes pains in the abdomen. Diet had no material 
influence on the secretion. Collected in a glass and left 
quiet, cream soon separated, and sometimes the milk ac once 
coagulated. After some hours standing, the butter separated 
and floated at the top in yebow drops. The milk had a 
slightly alkaline reaction. Its specific gravity was 1.024. 
In this case we see that, though there was an undoubted 
and continuous secretion of milk, it was in small quantity, 
and I think it highly probable that the stories of men who 
have suckled and nourished infants at their own breasts are 
to be taken with many grains of allowance. Ordinarily, as 
you know very well, only two mammillae are seen; one upon 
the anterior surface of either pectoral muscle, and over the 6 
fourth ribs. Deviations from the normal number are, how- 
ever, seen, and Birkett says he has collected four cases, and 
witnessed one himself. The following is the account of the 
case he saw, which was in an adult male, two nipples 
being in the usual situations, and two below, over the fifth 
ribs. The two abnormal nipples were smaller than the 
others, but the areolse were distinct. One female child, the 
progeny of this man, the fourth, was born with four nipples, 
but she lived only to her fifth year. Of twelve children she 
was the only one inheriting this peculiarity. With the 
man, as far as his inquiries extended, it was not hereditary. 
In young infants, male equally with female, there is often 
an engorgement of the breasts, with a milky fluid. Sir 
Astley Cooper seems to have considered this as a constant 
phenomenon; but in this no doubt he was mistaken; it is, 
however, very common. 
This of itself is a matter of no consequence, but very 
often officious and ignorant nurses and mothers in their 
efforts to milk and squeeze out this fluid provoke by their 
manipulations inflammation, and even abscess of the mam- 
m£e. I have been obliged to open many such abscesses, 
some of them of quite large size. You ought to know about 
this that you may warn the attendants against their perni- 
cious interference. Should the breast seem to be distended 
and irritated with this secretion, very gentle rubbing with 
a liniment of sweet oil and belladonna will suffice to dis- 
perse it. Should the heat and redness show that inflamma- 
tion is imminent, or has actually taken place, you may try 
to prevent abscess by the application of cooling lead lotions, 
or, failing in this, apply a warm poultice, and when the 
matter is perfectly apparent make a slight puncture and 
evacuate it. At the period of puberty it occasionally hap- 
pens in the male, as well as the female, that the breasts en- 
large and become somewhat painful. This generally sub- 
sides in a short time, and needs no attention, but now and 7 
then more or less enlargement remains permanent, and it is 
said, that when this has been confined to one side, such 
breasts have been removed on suspicion of cancer.. Con- 
cerning this enlargement of the breasts in young men, there 
is a very curious passage in Paulus iEgineta, which I give 
you from the Sydenham Society’s translation, by Mr. Francis 
Adams, togetaer with the commentary of the learned trans- 
lator : 
“ As at the season of puberty the breasts of females swell 
up, so in like manner those of the males also swell to a cer- 
tain extent; but for the most part they subside again. In 
some cases, however, having acquired a beginning they go 
on increasing, owing to the formation of fat below. 
“ Wherefore, as this deformity has the reproach of effem- 
inacy, it is proper to operate upon it. Having, therefore, 
made a lunated incision below the breast, and dissected away 
the skin, we unite the parts by sutures. 
“But if, as in women, the breast incline downward, 
owing perhaps to its magnitude, we make in it two lunated 
incisions, meeting together at the extremities, so that the 
smaller may be comprehended by the larger, and dissecting 
away the intermediate skin, and removing the fat, we use su- 
tures in like manner. But if through mistake we should cut 
away too little, we must again remove what is redundant, 
and apply the remedies for fresh wounds.” 
“ Commentary : The description given by Albucasis is so 
like our author’s, that there can be no doubt of its being 
borrowed from him. When there is a great redundance of 
fat and flesh, he directs us to make two lunated incisions, 
the larger comprehending the smaller, and having dissected 
away the intermediate skin to unite the edges by sutures. 
“ Haly Abbas repeats the same description in almost the 
same words. Rhases recommends the operation upon the 
authority of Antyllus and our author.” 
Whether we are to conclude with Velpeau, from this re- 8 
markable passage, that the enlargement referred to was 
common among the ancients, I cannot decide, but one thing 
we may safely do, and that is, to disregard the recommenda- 
tions of these ancient authors, and omit this operation from 
modern surgery. 
Not only at the infantile age, but at all periods of life we 
may meet with abscess of the male breast, but after infancy 
it is very rare. 
Heister mentions having opened such an abscess, which 
discharged two pounds of matter. Bransby Cooper also 
mentions a case, of nearly the same magnitude. Such ab- 
scesses may be caused by local violence, as from a blow, or 
arise spontaneously: but however they originate their 
treatment is the same as that of purulent collections else- 
where, and does not need any particular description. They 
are much milder in their symptoms, and less liable to be 
followed by intractable sinuses than abscesses of the female 
breast. 
Though information on the subject is very meager, I think 
we may say that of tumors of the male breast the malig- 
nant are the most common—two to one. Schirrus is the 
common form of cancer in this situation, though both epi- 
thelioma and encephaloid have been met with. There is 
nothing peculiar in these cases that need detain us, ex- 
cept to remark that it seems to be the fact that malignant 
disease advances much less rapidly here than in the female 
breast, nor is so likely to return, and when it does, not so 
quickly; the prognosis, in short, is better. 
Among the benignant tumors we find enumerated by au- 
thors—cysts, very rare; adenoid tumors, butyraceous tumors, 
very rare; calcareous tumor, one example, by Morgagni. 
I do not know of a recorded case exactly like the one that 
we have had before us, but, as I have already said, the sub- 
ject is a difficult one, information upon it being scanty, and 
hard to get at, so that we cannot advance any very dogmatic 9 
statement, but could not let so rare an opportunity pass 
without some attempt to improve it. 
CYST OP THE NECK. 
The patient we now introduce was before us three weeks 
ago, with a large tumor of the neck, and to-day he comes to 
show himself, entirely cured. His name is William Kin- 
ney, native of Ireland, laborer in a foundry, age, 41 years. 
About a year before his first visit to the clinic, he began to 
notice a swelling on the right side of his neck, just below 
the angle of the jaw, and behind the sterno mastoid muscle. 
It had grown steadily, and at the time of his visit was a 
large, conspicuous, and disfiguring tumor, measuring four 
inches in its longest, and two in its shortest diameter. It 
was perfectly smooth and regular in its outline, free from 
lobulation, tense and firm, but not hard in consistence. 
It gave an obscure feeling of fluctuation, and juelded, 
upon exploration with the needle of a hypodermic syringe, 
an ounce of clear, straw-colored fluid, thus settling definitely 
its character as a cyst or hygroma, or, as it is sometimes 
rather awkwardly called, hydrocele of the neck. The sub- 
jective symptoms connected with this tumor were slight, 
but rather peculiar and characteristic; there was very lit- 
tle—scarcely any—pain, but a feeling of disagreeable fullness 
in the head, sometimes connected with buzzing or whizzing 
noises, and when he stooped down, as he was obliged to do at 
his work, these became so severe that he was at last com- 
pelled to relinquish his emplojrment. You recognize in 
these phenomena, of course, evidence of interference with 
the return circulation from the brain. He had painted the 
surface of the tumor persistently with tincture of iodine, 
and also taken some medicines, of the nature of which he 
was ignorant, internally, all to no purpose. 
Having satisfactorily established the diagnosis, I proceeded 
in your presence to introduce a medium-sized trocar, through 10 
which I evacuated three ounces, by measurement, of a clear, 
straw-colored, slightly viscid fluid, which was highly albu- 
minous, becoming nearly solid upon the application of heat, 
but under the microscope showed a complete absence of 
structural elements. The trocar was introduced at the low- 
est part of the tumor, about half way between the mastoid 
process and the clavicle, and after the evacuation of the 
fluid, was left in situ, while an eyed probe was passed 
through it; the end of the probe was thus passed along the 
sac and made to protrude the integument at its upper end, 
when a slight incision—a mere puncture in fact—was made 
through the intervening tissues, the probe passed through, 
and by its means a seton, consisting of four strands of coarse 
ligature silk, with which its eye had been threaded, drawn 
through the longest diameter of the tumor, and tied loosely 
over the ou tside. This operation was performed on a Saturday, 
and I saw him every day afterward, and moved the seton to 
and fro, until the following Tuesday evening, when the in- 
flammation resulting from it was quite marked, and it was 
withdrawn. 
The tumor at this time was about half as large as it was 
at first, and hot and red. with a few of pus exuding 
from the lower puncture. It was evident to a careful palpa- 
tion that a good deal of the swelling present at this time was 
in the tissues outside the cyst. This inflammation and 
swelling soon subsided, and the man presents himself to-day 
absolutely cured of a serious and deforming tumor, with no 
scar, scarcely any pain, and absolutely no danger in the pro- 
cess. 
Tumors of the neck are among the most interesting and 
important of all surgical diseases. They may be divided, for 
convenience sake, into the solid and the cystic, with the 
latter of which only we shall concern ourselves at this time. 
And first among these we have to speak of the cystic de- 
generations of the thyroid body, the so-called cystic goitre 11 
or bronchocele. These consist of cysts of greater or less size, 
developed in an already enlarged thyroid. Their size is 
various; sometimes they present themselves as numerous 
small sacs disseminated through the substance of the bron- 
chocele ; again they may occupy its centre, their parieties 
consisting of the thickened tissue of the enlarged thyroid; 
or they may be grafted upon it as it were, or developed from 
its exterior. Their size is sometimes very great, and, occa- 
sionally, by growing inward as well as outward, they press 
upon the trachea and interfere with respiration. Their 
contents are very various, sometimes blood, sometimes clear 
yellow serum, but more frequently a thick, glairy, sticky 
fluid, of a dirty brown or gray color. They maybe diagnos- 
ticated by their situation, by rising and falling with the 
larynx in the act of deglutition, by a feeling of fluctuation 
more or less distinct, and by the use of the exploring needle 
or trocar. But they often escape recognition, and are con- 
founded with the other forms of bronchocele, on account of 
their depth from the surface, and not only the thickness, 
but also the soft, spongy character of the overlying tissues. 
Their treatment, as far as they require any treatment aside 
from the general treatment of the goitre, consists in the 
evacuation of their contents. But it is not of cystic goitre, 
to which I may sometime return in connection with the 
general subject of enlargement of the thyroid, that I wish 
to speak now particularly, but of the other forms of cyst of 
the neck. Of these I may just mention, as rare forms, the 
pre-laryngeal bursal tumors, and bursa of the hyoid bone, 
which are so seldom met with that I do not deem it best to 
complicate the subject by any attempt at a thorough de- 
scription of them now. The cysts of the neck most com- 
monly met with, are found in the lateral cervical regions, 
and resemble in all essential particulars the case which we 
have been studying together, and which has prompted these 
remarks. Their pathology, I must confess, is to my mind 12 
quite obscure. Whether they are degenerations of a peculiar 
kind of cervical lymphatic ganglia, sacs formed by inflam- 
matory isolation of certain areas of cervical fascia, or entirely 
new formations, can not be definitely asserted. But one 
thing seems highly probable ; that is, that as they differ in 
size, shape, and contents, they also probably differ in origin. 
Occasionally, cysts, like those of other parts of the body 
with steatomatous or melicerous contents, are found here, 
but they are not common. And why these larger and pecu- 
liar cysts should affect this region by preference, we can not 
say. 
Some years ago, I met with a man who had, on one side of 
the neck, near the median line, but unconnected with the 
thyroid body, a cyst as large as, and very nearly the shape of, 
a goose’s egg. projecting from the surface, as though the egg 
had been attached by its smaller extremity, and with a ten- 
dency to become pendulous. I wanted him to let me punc- 
ture it, but he refused, and told me that some time before a 
celebrated New England surgeon had punctured it with a 
pretty large trocar, and nothing but blood had come out, but 
this had come out in such quantity and with such persist- 
ence that he had very nearly lost his life by it, and he was 
determined not to have it meddled with any more; and no 
doubt he was quite right. The hemorrhage in this case may 
have been from some thin-walled and dilated vessel in the 
cyst, which gave way from the sudden withdrawal of the 
fluid support from within. The man’s account was too vague 
to enable one to judge definitely; but this is one of the pos- 
sible dangers in such cases. 
When these cysts am small and deeply situated, their diag- 
nosis is difficult, sometimes impossible, without the use of 
the exploring needle. This was the case in a patient under 
my charge last summer—a young lady, in whom there was 
a deep-seated and ambiguous swelling of small size, situated 
under and projecting slightly behind the sterno mastoid 13 
muscle. Exploratory puncture showed it to be a simple 
cyst, audit was cured by the injection of a few drops of tincture 
of iodine with a hypodermic syringe. The diagnosis of one of 
these tumors would rest upon the following points: the 
swelling in one of the lateral regions of the neck, smooth, 
unlobulated, round or more generally ovoid in shape, tense 
rather than hard in feel, sometimes with fluctuation, more 
often without or with this symptom obscure, yielding some- 
what to firm pressure and then returning to its shape when 
the finger is withdrawn. Though such an assemblage of 
symptoms as this might suffice to establish the diagnosis, 
still it will always be better to confirm it by a careful ex- 
ploratory puncture, avoiding, of course, the vicinity of large 
vessels or superficial veins. With such precaution, and a 
small instrument, exploration will always be safe and 
proper. 
The prognosis of these tumors is concerned only with their 
unsightliness, and such unpleasant symptoms as arise from 
interference with circulation from pressure; they do not in- 
crease indefinitely as a rule, and rarely reach a size much 
larger than in our patient. The most considerable excep- 
tion to this with which I am acquainted is a very large one 
recorded by Dr. J. Mason Warren, which reached from the 
mastoid process to the clavicle, and from the trachea to the 
vertebral column. 
With regard to treatment, four plans present themselves 
for consideration—excision, incision, injection with tincture 
of iodine, and seton. We leave out of view altogether ex- 
ternal applications, and the administration of medicines, as 
unworthy even of trial. 
Excision is to be avoided, if possible, as it is a difficult, 
severe, and dangerous operation. Though these growths 
seem to be freely movable, and unconnected with the deeper 
part, this is frequently delusive, and the posterior wall of 
the cyst is often firmly matted to important veins, arteries, 14 
and nerves, so that its dissection would be exceedingly 
tedious and precarious. Besides, such an operation has the 
disadvantage of leaving a very disfiguring scar. It is, there- 
fore, to be avoided, if possible. 
Free incision of the growth, and stuffing with lint, that 
it may fill up with granulations, is equally objectionable; 
indeed, more so, as being less radical and certain. It would 
leave even a worse scar, would involve long suppuration, 
which might extend to the deep fascia of the neck .and be- 
come dangerous. Unless it be in some rare emergency, it is 
to be condemned. 
Injection of these cyst with tincture of iodine is an ex- 
cellent mode of treatment, and deservedly in high favor 
with surgeons. I do not know with whom it originated. 
At a recent congress of German surgeons, Esmarch spoke 
very strongly in favor of it, and mentioned a number of 
cases in which he had used it successfully. The details of 
the operation are very simple. After the evacuation of its 
contents, the cyst is injected with a small quantity of 
tincture of iodine, proportionate to its size, which is brought 
in contact with all parts of the interior by gently rubbing 
and kneading the tumor. It causes more or less active in- 
flammation, often with slight suppuration, and final disap- 
pearance of the disease. But it is not infallible. It some- 
times fails, and sometimes it sets up an undesirable amount 
of inflammation. 
The plan of treatment by the introduction of a seton, 
which we have used with such gratifying success in this 
patient, originated, I think, with some French surgeon, 
whose name I have forgotten, about 1836 or 1837. This, cer- 
tainly, is a very excellent mode of treatment, and if it 
always acted as perfectly as in the present instance, would 
leave nothing to be desired. But it, also, fails sometimes. 
At a meeting of the Philadelphia College of Physicians, 
held January 17, 1872, Dr. Walter F. Atlee reported a case of 15 
this form of tumor occupying the submaxillary region on 
the left side. The patient was a young man, aged twenty- 
five years. The tumor was about the size of a goose-egg, 
and had existed for several years. For more than a year 
attempts had been made to effect a cure by means of a seton, 
injections of iodine, and by repeated tappings. Extirpa- 
tion, which had been delayed on account, of its extreme 
difficulties and dangers, was finady resorted to, and the 
patient recovered. It seems to me that extirpation should 
be confined to cases like this, in which other means have 
been tried and failed. 
As between injection of iodine, and seton, both excellent 
plans, both supported by the authority of great names, and 
with both of which I have obtained perfect cures, have we 
anything to guide us to a choice? Yes, I think we have. 
Where the tumor is large, particularly where it is of such a 
shape, and so situated that a large portion of the cyst is in 
contact with the deep structures of the neck, the seton is to 
be preferred, because we can withdraw it at pleasure, and 
thus, to some extent at least, limit the amount of inflamma- 
tion which is set up, whereas the tinct. iodine once injected, 
we have no control over the result, which, in such cases as 
those indicated, may proceed to an undesirable extent. If, 
however, the tumor is small, or has but a limited attach- 
ment, we may, perhaps, prefer the tinct. iodine, as rather 
less painful and annoying to the patient. Whichever of 
these plans of treatment is resorted to, if it fails, we should 
then try the other, and failing in both, then have recourse 
to extirpation.