for the purpose of guarding more efficiently against hemorrhage. That hemorrhage is not always prevented even by exercising the greatest caution is well known. The writer has seen profuse hemorrhage from both lingual arteries after amputation of the tongue by the écraseur. Rhinologists and laryngologists have invented minute écraseurs upon which they rely almost exclusively in the removal of polypoid growths from the nasal cavities and the larynx. The general surgeon at the present time seldom resorts to the écraseur. Mr. Hutchinson prefers

FIG. 53.-Wire écraseur.

it to the knife or the scissors in removing the tongue, but few surgeons could be induced to follow his example.

Avulsion. The removal of a pedunculated tumor by torsion is accomplished by grasping the pedicle, as close to its attachment as possible, with a pair of strong forceps and twisting it around its axis until the tumor is torn from its bed. This has been a favorite method of removing polypoid growths of the nose and the uterus. If the tumor is soft, the removal is often incomplete, and a return of the growth is the rule; if the pedicle is large and firm, unnecessary damage is often inflicted upon the organ to which the tumor is attached. Avulsion should give way to the galvano-caustic wire, to the écraseur, or to enucleation.

Extirpation. The general surgeon, with few exceptions, removes all tumors by extirpation. This method of eradicating tumors has precision. The knife can be made to include any tissue that may present a suspicious appearance, and it enables the surgeon to examine the tissues as he proceeds with the operation, and thus to outline more accurately the limits of the tumor. The operation can be performed painlessly by placing the patient under the influence of an anesthetic, and the wound can be made to heal by primary intention. The contrast between the speedy and painless removal of a tumor by excision and the slow and painful destruction by caustics is great. The wound left after the use of caustics has to heal by a slow process of granulation, and, as so often happens, incomplete removal transforms a subcutaneous into an open ulcerating cancer, with all the risks and inconveniences incident to such a condition. Incomplete removal by caustics invariably results in aggravation of all the local conditions, as the inflammation which follows cauterization imparts a new stimulus to

tumor-growth. The risks of hemorrhage and infection are much greater after cauterization than after excision. The removal of benign tumors, carcinoma, and sarcoma by extirpation should be made the rule, and the use of caustics be reserved for exceptional cases of carcinoma.

The idea that the results after extirpation of malignant tumors are better if the wound suppurates and heals by granulation is wrong both in theory and in practice. Inflammation is one of the most influential factors in effecting a speedy recurrence if the tumor has not been removed completely. In extirpation of tumors it should be the aim of the surgeon to secure healing of the wound by primary intention. If the margins of the wound cannot be brought into apposition by suturing, owing to the removal of an extensive area of skin with the tumor, the margins should be approximated as far as possible by tension-sutures, and the remaining surface be covered with a Wolfe skin-graft or with a mosaic of Thiersch skin-grafts. For the purpose of preventing woundcomplications, and with the view of securing speedy healing of the wound and of obtaining an ideal functional and cosmetic result, it is absolutely necessary to resort to the strictest antiseptic precautions in the extirpation of a tumor, irrespective of its size or its location.

The instruments should be sterilized by boiling for at least ten minutes in a 1 per cent. solution of carbonate of soda. Sterile ligatures, sutures, and gauze sponges should be used. The field of operation and the hands of the operator and of his assistants should be disinfected thoroughly by scrubbing with warm water and potash soap for at least five minutes, followed by washing in a 1: 1000 solution of corrosive sublimate. If the tumor occupies any of the large cavities, the patient must be prepared thoroughly for the operation by preliminary treatment continued for several days. The external incision should be amply large, to facilitate deep dissection. The danger of a wound is no longer estimated by its size. The attempt to remove tumors through small incisions is attended by greater risks of injury to important structures than when the parts we wish to avoid are well exposed by a large incision. The incision should be made in a location and direction which will render the tumor most accessible and which will not implicate important structures. It must be remembered that tumors often displace important vessels and nerves, and on this account special care is necessary to avoid these structures when displaced. In operating upon the extremities the incision should be made parallel with muscles. In extirpating tumors of the neck an incision in the direction of the sterno-cleido-mastoid muscle is usually made. A transverse incision is preferred by some operators in the removal of tumors of the thyroid gland. Submaxillary growths should

be approached through a slightly-curved incision below the border of the lower jaw. In amputations of the breast the incision is prolonged behind the border of the pectoralis major muscle to the apex of the axilla. Tumors of the groin are laid bare by making an incision. parallel with and a little below Poupart's ligament, and joining it by a vertical incision over the femoral vessels extended to the apex of Scarpa's space. A slightly-curved incision affords more room than a straight one. If the skin or the mucous membrane over the tumor is implicated, it is included between two elliptical incisions and is removed with the tumor. After a benign tumor has been reached, cutting instruments are laid aside and the tumor is removed by enucleation, using for this purpose the finger, Kocher's director, or bluntpointed scissors. Extirpation of osteoma and chondroma requires the use of the chisel or the saw. Some cysts have such firm attachments that enucleation is impracticable, in which event their removal is effected by careful dissection. If the extirpation of a tumor requires a preliminary myotomy, the muscle should be united by buried absorbable. sutures before the external wound is closed. If a nerve or a tendon is accidentally or intentionally cut, it is united in a similar manner. If an important fascia has been divided, it is separately sutured. benign growths are aseptic pathological conditions, the external wound. can be closed throughout by sutures and sealed. The after-treatment should include rest of the part operated upon, which can be secured by rest in bed, bandages, splints, etc. Operations for carcinoma and sarcoma are attended by great difficulties, as with the tumors the surgeon must include a zone of tissue surrounding them, and must usually extend the operation far into apparently healthy tissue to reach and remove the products of regional infection. Two great difficulties confront the surgeon during the course of the operation. In the absence of any limiting structures he is often in doubt concerning the amount of tissue he should include with the tumor, and, again, to what extent he should invade the vicinity in his attempts to eradicate the disease. No definite rules can be laid down to guide the surgeon in deciding these most important points of the operation. He must take pathological anatomy as his guide. It is well known that sarcoma follows connective tissue, blood-vessels, nerve-sheaths, and muscles. The surgeon must therefore include as much tissue in the direction of these pathways as is permissible with the importance of the structure involved. The amount of tissue to be included must necessarily vary with the character of the tumor, its location, and the importance of the structures in its vicinity. The farther the tumor is away from important vessels and nerves, and the more tissue can be included, the better will be the

results. As a rough estimate the writer would say that the incisions should be made at least an inch away from the periphery of the tumor. Sarcoma of bone usually demands amputation, although recently successful local operations have been made in cases of circumscribed myeloid sarcoma. If amputation is performed, the entire bone should be removed; that is, amputation should be made through or above the proximal joint. In the removal of a malignant tumor enucleation must never be attempted: the tumor must be excised. Extirpation here means the removal not only of the tumor, but also of all infected tissues in its vicinity or in the same region. The knife or the scissors must be used from the beginning to the end of the operation. The extirpation of a carcinoma, unless the tumor involves a free surface and is recent and localized, must be followed by excision of the lymphatic glands of the same region, whether enlarged or not enlarged. The tumor and the string of lymphatic glands should be removed in one continuous piece by thorough and clean excision. It has been shown that carcinoma frequently selects the connective tissue as pathways for local infection; hence as much of the connective tissue as possible in the vicinity of the tumor should be included in the excision. Muscles are often divided or removed in operations for malignant tumors. Partial removal for malignant disease of organs not essential to life is bad surgery. In operating for malignant disease parts and tissues must be removed regardless of the cosmetic result. The surgeon who operates with a view of securing a good cosmetic result is very liable to perform an incomplete operation. The primary indication in the extirpation of a malignant tumor is to remove all infected tissues; the cosmetic result is of secondary consideration, and can be improved immediately or later by plastic operation. After operation it is advisable to watch the patient carefully, and in case of recurrence to repeat the operation. By following this course there is no doubt that the patient is made more comfortable and life is prolonged, and occasionally a radical cure is effected by repeated operations for local recurrence.

Contraindications to radical operations for malignant disease are1. Metastasis; 2. Extreme old age; 3. Regional infection beyond the reach of complete removal of diseased tissue without imminent danger to life; 4. Very extensive local infection, as in cases of diffuse cancer en cuirasse.

PALLIATIVE TREATMENT.

Palliative treatment is indicated in cases of inoperable malignant tumors. It consists in protecting the tumor against irritation, and, in open ulcerating tumors, in partial removal, antiseptic applications, and

the use of anodynes to subdue pain. If the tumor is on the surface, it should be protected against friction by the clothing by a compress of aseptic absorbent cotton held in place by a bandage or by strips of adhesive plaster. As soon as indications of ulceration appear, the surface should be disinfected thoroughly and be protected by an antiseptic dressing, so that when the tumor-tissue is exposed the ulcerated surface will be protected against infection. If the ulcer or fungous mass has become infected, it is necessary to correct the fetor by the employment of strong antiseptic applications. Chlorine-water, solution of permanganate of potash, saturated solution of acetate of aluminum, and solution of chlorinated soda (Labarraque's solution) are most efficient in correcting the putrefactive processes. A 10 per cent. solution of chloride of zinc, carefully applied with a camel's-hair brush to the dried surface of the ulcer, is one of the best disinfectants. The writer has found a solution of hydrate of chloral (2: 100) not only a good antiseptic, but also a local anodyne. The stronger antiseptics, creosote, carbolic acid, and corrosive sublimate, must be used with caution, as the prolonged use of even a weak solution might result in intoxication. Vegetable charcoal has been popular for a long time as a deodorizer. Great benefit often follows the removal of fungous granulations with a sharp spoon, followed by an energetic use of the actual cautery. This treatment is frequently resorted to with decided temporary improvement, so far as the local conditions are concerned, in the palliative treatment of inoperable carcinoma of the uterus. Bleeding from the ulcerated surface, commonly of capillary origin, is best controlled by applying a few layers of gauze saturated with liquor. ferri sesquichlorati, over which an antiseptic tampon is applied, and the whole kept in place with the dressing applied to the ulcer by broad strips of adhesive plaster. If a large vessel is the source of hemorrhage, and can be tied neither in loco nor at a distance, the antiseptic tampon will have to be relied upon. Very little is to be expected in the way of alleviating pain from local anodynes; of these, cocaine has proved the most useful. A strong solution (10 per cent.) of cocaine applied to ulcerating carcinomata of the cavity of the mouth has done much to relieve pain and dysphagia. Arnott derived great benefit from cold applications. The cold coil or the ice-bag deserves a trial as a local anesthetic. Subcutaneous injections of morphia have to be relied upon to allay pain and to procure sleep. The smallest dose possible should be commenced with; the dose must be increased rapidly as the pain increases in severity and the patient becomes habituated to the use of the drug.