be by the bloodless or by the bloody method. The bloodless removal of such tumors may be accomplished by the application of such caustics as arsenic, chloride of zinc or Landolfi's paste, by the actual or by the Paquelin cautery. The pastes just mentioned, although still much resorted to in France, are not often employed by German operators, on account of their uncertain action.

The "Paquelin" may be employed with advantage when the tumors are very large and vascular, or when the muscles of the chest or the ribs are already involved. The instrument is not suited to the removal of the axillary glands. Ever since Fabricius of Aquapendente and Fabry von Hilden first enucleated the glands by the fingers through a cutaneous incision, this method has been employed, and no improvement has been suggested.

Galen first described the operation for amputation of the breast by the knife. It was afterwards suggested to use the actual cautery in connection with the knife.

Amputation may be either partial or complete, partial in benign tumors, but always complete in those of a malignant nature, whether the whole gland is involved or not.

After the patient is anesthetized, and the skin over the breast thoroughly washed with soap, a cutaneous incision is made corresponding to the longest diameter of the tumor; the latter, if enclosed by a capsule, may then be easily enucleated. When the tumor is malignant the sound tissues should be excised for at least an inch beyond its margin. When the skin is not movable over the tumor but adherent, or is already diseased, it must be excised far beyond the limits of the involved tissues. When the pectoral muscles are involved, the diseased tissue must be removed, and it may even be necessary, under certain circumstances, to exsect a rib. Indurations found in any portions of the adipose tissue or at the base of the wound, must be carefully removed by the scissors.

In order to extirpate the diseased axillary glands, the cutaneous incision should be extended, the fascia divided, and the fatty tissue with the glands removed by the finger. The vessels of the glands should be isolated by a blunt instrument, and then divided after tying with a double ligature. When the glands have be

come adherent to the vessels, the axillary vein may be injured, as occurred in my own experience; it must be simply ligated at both extremities at once; this will usually be in the vicinity of the thoracic vein. In some cases it becomes necessary to ligate the axillary artery; if the nerves are not exposed to any great extent, nor the collateral circulation interfered with, the arm will most likely not become gangrenous; the severest symptom will be oedema, or obstinate ulceration from the pressure of the bandages (Billroth). Before the wound is closed all hemorrhage must be completely arrested, ligatures being applied even to the smallest vessel. Billroth cautions operators against the use of styptics.

Helferich states that the proper and logical treatment to be pursued when the glands of the axilla are found carcinomatous, is to expose the infraclavicular fossa by forming a flap of skin and muscle dissecting the pectoralis major from the thorax and clavicle, thus exposing the lax tissues of the fossa together with the glands.

When the tension of the skin is not too great, the edges of the wound are united with interrupted sutures of silkworm gut. If there is much tension, silver wire, passed through lead buttons and fastened with perforated shot, may be used instead, or silkworm gut suture passed at some distance from the edges of the wound, and secured by wooden buttons. Maas, of Würzburg, suggested that parallel incisions be made at some distance from the wound, the skin between the incisions dissected from the underlying structures, and the wounds partially closed by catgut sutures made aseptic by a solution of corrosive sublimate; a small portion of each wound is thus left open for the discharge of the secretions, and no special drain is usually necessary. If portions of the wound still remain open, all should be united by sutures as far as possible, and the remainder packed with sublimate or iodoform gauze.

Protective silk is placed over the wound, a fold of iodoform gauze applied over this, then thick layers of salicylated cotton, the axilla being filled, and mackintosh finally passed around the

* Hoffa, loc. cit.

thorax. The arm is bandaged to the side, the forearm placed at a right angle and made immovable; this dressing must be firm but not too tight, and the fingers rest in a comfortable position.

Maas instead of this employs a dry, permanent dressing. He places over the protective silk a large compress of gauze made antiseptic by corrosive sublimate, the formula for which is bichloride of mercury 5 grammes (75 grains), common salt 500 grammes (7500 grains), glycerin 200 grammes (3000 grains), to 1000 grammes (15,000 grains) of gauze. Bandages of this gauze are passed about the thorax, shoulder and arm, the lower half of the forearm not being included in the dressing, but supported by a pillow. The skin is protected at the edges of the bandage by corrosive sublimate cotton. This dressing is not changed for fourteen days unless the temperature is high or the pulse frequent. The soiled gauze may be washed, disinfected and again dipped in the corrosive sublimate solution, so that the dressing is inexpensive. The wound usually heals under this dressing in about nineteen days. The normal mobility of the arm at the shoulder-joint is soon restored by massage and active and passive motion, after removal of the dressing.

When maliguant tumors of the breast cannot be removed, frequent disinfection with chlorine water or solutions containing permanganate of potash, iodoform, chinioidin, charcoal or carbolic acid should be employed. A cooling effect may be produced by applying cabbage leaves or an ice-bag. Billroth succeeded in deodorizing the ulcer by applying dried figs boiled in milk, thereby inducing a lactic acid fermentation. The use of artificial gastric juice is of little value for this purpose. Parenchymatous injections of nitrate of silver, as suggested by Thiersch, or of tincture of iodine, Fowler's solution, carbolic acid, and mercury, have proved ineffectual. Inoculation with the virus of erysipelas, as practiced by Fehleisen, is dangerous and its value doubtful. Electrolysis has produced no favorable results. Iodide of potash, arsenic, belladonna, condurango and Chian turpentine internally have been recommended and tried, but little can be expected from any of these. Narcotics will be required to relieve the pain, and among these are chloral hydrate, administered internally or by the rectum, morphia, internally and sub

cutaneously, and, for local anesthesia, cocaine in from 2 to 20 per cent. solution.

If large vessels become eroded causing hemorrhage, it must be arrested by styptic cotton and compresses secured by bandages. Powdered tannin dusted upon the ulcer, or washing with a decoction of oak-bark, will lessen the tendency to hemorrhage, diminish the amount of secretion, and deaden the hypersensitiveness of the surface of the ulcer.

CHAPTER IV.

NUTRITIVE DISTURBANCES OF THE FEMALE BREAST.

INFLAMMATIONS. TUBERCULOSIS. SYPHILIS. ABNORMAL SECRETION.

INFLAMMATIONS of the breast may be acute, subacute or chronic; they are, however, only in rare instance non-puerperal.

Occurring in the new-born they are most common a few days after birth. Swelling is usually bilateral, the breasts enlarging to the size of a walnut; their ducts are dilated and almost cavernous (Th. Kölliker); the skin, at first pale, becomes reddened; the nipple is effaced or retracted; a few drops of colostrum may be expressed, and there is considerable pain. Abscesses are rare, as most inflammations of this character are relieved in a few days by applications of lead-water, inunctions of the breasts, and dressings of raw cotton. In only a few instances have I found it necessary to incise abscesses in such cases. These inflammations, equally common in males and females, may be produced by injuries of the glands during or after labor.

Subacute inflammations, or attacks of mastitis followed by formation of abscesses, are sometimes observed shortly before or even after puberty, or during pregnancy. A case begins with the formation of nodules in the breast, which enlarge and become adherent to the skin; the latter being congested, suppuration results, ending in perforation. The abscess may thus perforate the skin, but more frequently gradually disappears under the use of

iodide of potash, belladonna ointment or applications of lead

water.

Chronic inflammations and cold abscesses are of much less frequent occurrence. In some instances they are caused by diseases of the ribs; they may also occur in young scrofulous girls (Gross).

The description of tuberculosis of the female breast is not yet determined, as the typical bacillus has not been found in the nodules formed in the gland. The possibility of its presence cannot be doubted, but the cases must be extremely rare. In 1882 Ohnacker critically examined all the reports that had been published, and added two new cases from the surgical clinic at Giessen with illustrations and a description of the microscopical examinations. His illustrations showed the presence of only the giant-cells and epithelioid granulation cells; at the time his patients were operated upon, however, the tubercle bacillus of Koch was comparatively unknown. According to Ohnacker, the disease begins in the epithelium of the excretory ducts, and extends to the adjacent tissues. Caseation of the glands and of the pus surrounding the indurated tissues is always present in tuberculosis of the breasts.

The occurrence of syphilitic disease of the breast is also extremely rare. Hennig reports a case in which a woman 55 years of age was bedridden for four years from syphilitic disease of the bones, when a gumma of the breast appeared; the diagnosis is not beyond question, however, as no microscopical examination of the tumor was made. I have seen but two cases of indurated ulcer of the nipple or areola in more than 10,000 female patients treated.

Nodulated indurations and contractions of the parenchyma of the breast may develop as a result of chronic mastitis. Such affections begin as a small-celled infiltration, lead to dilatation of the excretory ducts and acini, and form a hard cicatricial tissue. The nodules are painless, freely movable over the pectoral muscles, and unaccompanied by swelling of the axillary glands. This condition has been designated cirrhosis mamma (Wernher), elephantiasis mamma dura, and mastitis interstitialis diffusa et circumscripta. Whenever the condition causes symptoms distress