become so numerous as to be in the way, the vessels are to be ligated before completion of the operation. Hot towels applied for a few moments will arrest the parenchymatous oozing. If the subclavian vein is injured, lateral ligature usually suffices. Complete arrest of bleeding must be secured before closing the wound. Complete aseptic conditions obviate the necessity for drainage. Copious gauze dressings are to be applied, covered by sterilized

FIG. 3.-Pectoralis major muscle removed and pectoralis minor retracted. Mass of fat and lymphatic glandular structures to be removed.

non-absorbent cotton, and held in place by a snugly fitting chestbinder with hollow places cut under the arms. The arm is wrapped in sterilized cotton and secured across the chest by a wide roller bandage for the first few days. If all goes well the dressings are not disturbed for a week, at the end of which time the sutures are removed.

When the exposed wound-surface cannot be covered entirely

by the skin flaps the space may be filled with Thiersch skin transplantation-strips. This may also be done upon the granulating surface as a secondary procedure.

The prognosis of the operation will vary with the stage of the disease at which interference is undertaken. Death resulting from the operation itself is rare in uncomplicated cases. Before the introduction of aseptic methods the mortality was twenty-five per

Healing takes place in about fourteen days. Recurrence of the disease to be expected in late cases within three months. The immunity against extension, both regional and dyscrasial, will be in direct proportion to the advances made by the disease at the time of the operation, and the completeness of the latter. Prompt recurrence may follow an incomplete operation, even when undertaken in the very earliest stages, while a complete operation may afford comparative or complete immunity even when the disease is well advanced. The lymphatic glands are usually involved in a recurrence before the cicatrix. Next in frequency the skin is attacked in the shape of scattered lenticular indurations. These should be promptly removed. Keloid developing in the cicatrix or at the site of suture-punctures is to be looked upon with suspicion. If a year elapses without a recurrence the prognosis thereafter is favorable, but cure cannot be said to have been accomplished until at least three years have elapsed (Volkman).

The movements of the arm are interfered with to a remarkably slight extent, particularly those of abduction; in a number of instances in which I have had the opportunity of observing the conditions at the end of a year, almost a perfect restoration of the functions of the member has taken place. Impairment of abduction is sometimes due to shortening of the cicatrix at the site of the incision which crosses the front of the axilla; under these circumstances a plastic operation may be indicated. All tendencies toward recurrence should be promptly met by further operative interference, although the ultimate prognosis is more grave under these circumstances. The average duration of life, after operation in cases in which recurrence takes place, is thirtyfour months, a distinct average gain of a year over cases which are permitted to pursue their natural course following the discovery of the tumor. These figures are taken from the statistics compiled before the introduction of the radical procedures now employed. While slightly greater risks are taken in the latter,

as compensation for this greater benefit is derived, in that increased immunity against recurrence is secured.

We will now proceed to carry out the operative procedure which I have outlined for you. All being in readiness and the patient anesthetized, the arm is held either at right angles with the body, or placed behind the patient's head. The first incision commences at the humeral attachment of the pectoralis major muscle, is carried parallel for a short distance with its clavicular portion, thence curves around the upper, inner, and finally a portion of the lower margins of the breast, in succession. A second incision commences at the point where the first joins the circumference of the breast, and is carried around the lower and outer margins, thence joining the termination of the first incision (Fig. 1). A third incision is sometimes employed, which commences at the middle of the clavicle and extends directly upward to join the first. The skin-flaps are turned back with as little attached fat as possible, and the breast dissected from the muscle and removed (Fig. 3). The case is one eminently demanding removal of the pectoral muscle. This is extirpated by first dividing the sternal and costal attachments. A time-saving measure at this stage is to pass the fingers of the left hand beneath the muscular strips of attachments, dividing these with the scissors, the fingers serving as a guide to the lower scissor-blade. In loosening its clavicular attachments, if the skin is not easily retracted, the third incision is employed. The ablation of the muscle is completed by section of its attachments to the humerus. A mass of lymphatic glands is revealed beneath the outer edge of the pectoralis major muscle, and there is also found another mass lying beneath the pectoralis minor and running along the vessels. There is a suspicion of involvement of the latter muscle; this is divided across its middle and the two portions removed.

The axillary fascia is now opened up and the subclavian vein exposed and identified. This identification of the vein I consider a very important step at this stage of the operation. The axillary cavity is now carefully cleared from connective tissue, fat, and lymphatic glandular structures, these being removed in one mass from the triangular-shaped space behind the pectoralis minor muscle.

All hemorrhage being arrested, we will now proceed to close the wound. The axillary flap is first forced well up in position. by a pad of sterilized gauze placed into the axilla, so as to elevate the fornix of the latter as much as possible. This obliterates the

arm.

"dead space," which would otherwise exist and render drainage necessary. The thick cicatricial tissue left after healing of this dead space would also tend to greatly limit the movements of the While this is being done the arm is brought down to the side. The wound is closed as completely as possible by means of interrupted sutures of silkworm-gut, where tension is considerable, and by the subcuticular suture where the skin edges can be readily approximated.

Where there is extensive involvement of the skin, particularly under circumstances of recurrence, it will be necessary to make the incisions still further away from the margins of the breast or diseased area, and fill the gap thus occasioned by a flap taken from the lateral and posterior surfaces of the chest wall.

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EDITORIAL.

LODGE DOCTORING.

The Associated Physicians and Surgeons of Santa Clara County, Cal., numbering in all 124, have unanimously entered into a compact not to render medical or surgical services to the members of any lodge, society, association, or organization for less compensation than is charged the general public for such services. Of course, this agreement does not apply to hospitals or other charitable institutions. Investigation had shown that medical compensation for lodge work averaged about 15 cents on the dollar. In a letter sent us by the secretary, Dr. Lincoln Cothran of San José, he says:

The main incentive of the persons who band themselves together in lodges is to get cheap doctoring; they are willing to take, but not to give. They belong to protective unions, and the same right should not be denied physicians. Ninety-nine per cent. of these people are able to pay reasonable fees to physicians, but will not do so as long as a few doctors in every community, for the sake of immediate gain, can be induced to stand as driven guys to the lodge politicians. No preacher or lawyer would give his services to these people for 15 cents on the dollar. No grocery store or merchandise firm would contract to supply these lodges with goods at 15 cents on the dollar of actual worth.

Our California friends are to be congratulated on this action.