by lateral flaps, and Liston by anteroposterior flaps. Forneaux Jordan's method consists in dividing the soft parts low down, tying the bloodvessels on the face of the stump, shelling out the femur from the soft parts, and disarticulating.

XXXVIII. DISEASES OF THE BREAST.

Mammillitis and Fissure.-The nipple may inflame as a result of injury, but the condition is rarely encountered except in a woman who is nursing a baby. It is most common after a first pregnancy, when the nipple is deformed or when the skin is delicate. The nipple is slightly injured during nursing, and the epithelium is macerated by the milk and saliva. If the inflammation is not arrested, an area excoriates or an irritable ulcer forms (a fissure). This fissure is often surrounded by an area of acute inflammation, and nursing causes intense agony. Because of the pain the mother is apt to extend the intervals between nursing, and as a consequence the breasts become swollen with retained milk. The ulcer not unusually bleeds when taken by the child. Besides the fact that a fissure causes pain to the mother, it often leads to grave trouble. It is a suppurating area, and as such may lead to abscess of the mother's breast, or may impair the health of the nursing child.

Prevention of Fissure.-During pregnancy the nipples should be carefully attended to. They should be washed often in sterile water and bathed in alcohol, and if retracted ought to be drawn out repeatedly. During lactation the nipples are washed in sterile water, dried, and dusted with borated talc powder as soon as an act of nursing is completed. Washing the nipples regularly with the following solution tends to prevent the formation of a fissure: iodid of mercury, gr. ij; alcohol, 3jss; glycerin and distilled water, aā a pint (Lepage). If a small abrasion appears, order the woman to wear a nipple-shield during nursing, and after each act of nursing to wash the part with hot sterile water, dry, and dust borated talc over the surface. If a fissure forms, wean the child at once, and dry up the milk in both breasts. It is useless to try to dry it up in one breast. Milk may be dried up by applying ointment of belladonna locally and administering iodid of potassium internally; by strapping the breasts with adhesive plaster (Parker); or by applying to the nipples six times a day a 5 per cent. solution of cocain in equal parts of glycerin and water (Joise). The fissure is not treated by ointments. These preparations

are septic, prevent drainage, and aggravate maceration. Wash the fissure twice a day with peroxid of hydrogen, dress it with gauze wet in boric-acid solution (gr. x to 3j of water), and cover the dressing with waxed paper. If the fissure resists

treatment, touch it with lunar caustic.

Acute Mastitis and Abscess.-Acute inflammation of the breast, as a result of injury of the breast or nipple, may occur in either sex at any time of life. Very commonly in both sexes a few days after birth the breast becomes distended with a material which in reality is milk. The fluid is usually small in quantity. The process is physiological, and, as a rule, ceases spontaneously (Guelliot). If it lingers, the application of belladonna ointment will stop secretion. If the nurse meddles with and tries to squeeze out the fluid, acute mastitis is apt to arise in one gland, or occasionally in both. The skin of the breast reddens, the gland swells and becomes tender and painful, the child loses its appetite and becomes feverish, restless, and sleepless. Such a condition is treated by the local use of lead-water and laudanum. If pus forms, the local signs and constitutional symptoms are aggravated. Evacuate the pus, dress with hot antiseptic fomentations, and be sure that the child is well nourished. Tonics and stimulants are indicated.

A condition identical with the secretory activity of the glands of the new-born may occur in either sex at puberty. The methods of treatment are the same in both cases. As a matter of fact, rarely more than one lobule at this period inflames, and suppuration is most unusual.

Mastitis is most usually met with in a woman who is nursing a child, and is due to bacterial infection. Primipara are particularly liable to develop mastitis. So are women with deformed nipples. In many cases an abrasion of the nipple exists, and through this breach of continuity organisms gain entrance to the breast-tissue. The abrasion may be so slight that it can only be detected when the nipple is examined through a magnifying-glass (Marmaduke Shield). Streptococcic infections are very generally due to inoculation of a fissure of the nipple. Organisms may pass up the milk-ducts, coagulating the milk and penetrating through the walls of the acini. Staphylococci usually adopt this route in reaching the breast-tissue. Occasionally causative organisms reach the breast through the arteries (in septicemia and in septic wounds of the genital organs).

Symptoms. There are pain, swelling, and tenderness in the breast, and in most cases a fissure or abrasion exists.

There is a febrile condition. Occasionally a chill ushers in the attack.

Treatment.-Stop nursing. Arrest the secretion of milk. Treat the nipple as advised on page 859. Support the breast and apply ichthyol ointment or lead-water and laud

anum.

A mastitis may undergo resolution; it may terminate in organization and induration; it may eventuate in suppuration. Acute abscess of the breast follows an acute mastitis. There may be but one area of suppuration, or multiple foci may exist, which eventually fuse. The symptoms of mastitis, local and constitutional, are greatly aggravated. After a time the skin becomes dusky and edematous. The axillary and superficial cervical glands enlarge. The abscess will eventually open spontaneously at one or more points, leaving branching fistulæ. A superficial abscess is situated just beneath the nipple, and pus may flow from the nipple.

An intramammary abscess is in the depths of the gland. There are often multiple foci of suppuration. Nodules are felt in the gland, pus may run from the nipple, but cutaneous redness is late in appearing.

Retromammary abscess is a rather rare condition. It may occur alone or be associated and connected with an area of intramammary suppuration. This condition may result from metastasis or from caries of a rib. The breast is lifted up by the fluid beneath it.

Treatment.-Open a superficial abscess by an incision. radiating from the nipple. Treat as any other acute abscess. An intramammary abscess should be opened by a radiating incision, and pockets of pus should be broken into with the finger. An examination is made to determine if a retromammary abscess also exists. If this is found to be the case, an incision is made at the point of junction of the thorax and mammary gland, and at the lower border of the gland. The gland is raised from the chest-wall, the pus evacuated, and a drainage-tube is inserted. If retromammary abscess exists alone, make the last-named incision in the first place.

Chronic Mastitis.-This condition may be present in only a portion of the breast, or may attack many lobules (lobular mastitis). The ordinary form may arise after weaning a child, or may be due to a blow, to the pressure of corsets, or to numerous slight traumatisms. It may occur in the young, the middle aged, or the old. The patient has slight pain at times in the gland. Examination detects a firm,

elastic area, which is somewhat tender and does not present distinct edges. The skin is not adherent to the mass unless suppuration occurs. If the mass is pressed against the chest. by the surgeon's fingers, it becomes evident that no real tumor exists.

Treatment. Remove any cause of irritation. Support the breast in a sling. Apply ichthyol ointment. During the night employ a hot-water bag. If pus forms, treat as before directed.

Chronic lobular mastitis is a condition in which numerous lobules become indurated. The real cause of this condition is unknown. It may occur at any age after puberty, and often attacks both breasts. Such a breast is apt to be painful, especially at the menstrual periods; it feels unnatural, solid, and careful examination detects numerous indurated areas, each of which is of small size. At the menstrual period the breast enlarges and new nodules may be detected. In some of these cases violent neuralgic pains are present in the gland (mastodynia). Chronic lobular mastitis is apt to lead to cyst-formation. When cysts form fluid may occasionally discharge from the nipple.

Treatment.-Support the breast and apply ichthyol ointment or belladonna ointment. Examine the generative organs and correct any existing abnormality. Improve the general health by good food, tonics, and open-air life. In cases where multiple cysts are known to exist the question of treatment is uncertain. There seems to be no doubt that such cases tend in some instances to eventuate in cancer. We believe that the proper treatment is extirpation of the breast. Tuberculosis of the Mammary Gland.-(Sce page

108.)

Cysts and Tumors of the Nipple and the Mammary Gland.-Tumors are rare in the nipple, but do sometimes occur. The following growths are occasionally seen: fibroma, angeioma, papilloma, myxoma, myoma, and epithelioma. Sebaceous cysts of the nipple and areola are not very unusual. A cancer of the nipple may be a primary growth, or may be secondary to gland cancer. Primary epithelioma of the nipple presents the same general characters as epithelioma in any other region. It begins as an indurated area in the areola, or an excoriation of the nipple. Ulceration soon occurs. The ulcer is irregular in outline, has hard edges, furnishes a foul red flow, and the discharge is sanious and fetid. The mammary gland becomes infiltrated at an early period. The subclavian glands enlarge, and later the axillary glands.

This growth must not be confounded with a chancre of the nipple.

Treatment of Tumors of the Nipple.—Innocent tumors are to be excised and the breast need not be removed.

Epithelioma of the nipple requires the complete extirpation of the breast, and also the clearing out of the lymphatic contents of the axilla, and possibly of the subclavian triangle.

Paget's Disease of the Nipple (Malignant Dermatitis). This condition is a chronic inflammation of the epithelial layer of the nipple and areola occurring in women beyond middle life, and is a not unusual precursor of epithelioma of the nipple and of duct cancer. Paget's disease is not a simple eczema, it is not associated with the usual causes and attendants of eczema either local or constitutional, and is not cured by remedies which control the ordinary disease.

The diseased area is raw and red, and from it exudes copiously a thick, yellow discharge. In some cases Paget's disease is secondary to duct cancer, auto-infection of the nipple having been effected by the fluid flowing from the ducts. Investigations have shown the presence of psorosperms in an area of Paget's disease.

Treatment consists of removal of the entire breast and clearing out of the axilla and subclavian triangle.

Tumors of the Mammary Gland.-These tumors may be innocent or malignant. The innocent tumors are

Fibro-adenomata or Cystic Adenomata, Myxomata, Villous Papillomata, and Angiomata.-It is maintained by most authorities that any innocent tumor of the gland may and often does become malignant.

Fibro-adenoma.-The nomenclature of these growths is in a state of great confusion. The name of fibro-adenoma was given by Cornil and Ranvier to the same sort of growth which the younger Gross called a fibroma, Billroth an adeno-fibroma, and Sir Astley Cooper a chronic mammary tumor. It is doubtful if a pure fibroma ever occurs in the mammary gland (Senn). A fibro-adenoma consists of acini surrounded by fibrous tissue. Each of these structures proliferates, but the fibrous tissue does so much more rapidly than the glandular. A growth of this character is surrounded by a capsule, and is movable. It is firm, elastic, lobulated, superficially situated, and of slow growth. It is unassociated with retracted nipple, glandular enlargement, adhesion to the skin, or cachexia, and may occur at any age up to fifty, but is most common between