the chest down to the waist, the breast itself, the axilla, the side and the back must be sterilized. It is necessary to have, besides scalpels, and the ordinary instruments for an operation, a great number of hemostatic forceps (80 to 100). Place the patient recumbent, with a sand-pillow under the shoulder of the affected side. The shoulder is right at the edge of the bed, and a nurse holds the arm from the side. Halsted describes his operation as follows: The skin incision is made as shown in Fig. 331, and is carried at once through the fat. The triangular skin flap (a, b, c,) is turned

FIG. 331.-Halsted's operation for carcinoma of the breast: the first incision.

down. The costal insertions of the great pectoral muscle and the muscle are split between the clavicular and costal portions and up to a point on the clavicle opposite to the scalene tubercle, and at this point the clavicular portion of the muscle and the tissue overlying it are cut through close to the clavicle, and the apex of the axilla is at once exposed. The cellular tissue under the clavicular portion of the muscle is dissected from the muscle, and the splitting of the muscle is continued on to the humerus. The part of the muscle to be removed is cut through close to its humeral insertion. The whole mass circumscribed by the first incision (skin, breast, areolar tissue, and fat) is raised with considerable force in order to put the submuscular fascia on the stretch as it is stripped from the thorax close to the ribs. It is well to include the delicate sheath of the pectoralis minor muscle. The lower and outer boundary of the lesser pectoral having 1 Johns Hopkins Hosp. Reports, vol. iv.; Annals of Surg., Nov., 1894.

been passed and exposed, the muscle is cut at a right angle to its fibers and a little below the middle. The tissue over the minor muscle near its coracoid insertion is divided as far out as possible, and is then reflected inward to prepare for the reflection upward of this part of the minor muscle. The upper portion of the minor muscle is retracted upward (Fig. 332). The small blood-vessels under the minor muscle are carefully separated from it, are dissected out very

clear, and are ligated close to the axillary vessels. Having exposed the subclavian vein at the highest possible point below the clavicle, the contents of the axilla are dissected away with a sharp knife and the vein and its branches are stripped absolutely clean. The loose tissue about the artery and the nerves should also be removed. When the vessels are cleared the axillary contents are rapidly stripped from the inner walls of the axilla and the lateral wall of the thorax. The fascia which binds the mass to the chest is cut close to the ribs and the serratus magnus muscle. Just before reaching the junction of the posterior and lateral walls of the axilla, an assistant draws the triangular flap of skin outward in order to spread out the tissue which lies upon the subscapularis, teres major, and latissimus dorsi muscles. The operator cleans the posterior wall of the axilla from within outward. The subscapular vessels are clearly exposed, and are caught before they are cut. In some cases the subscapular nerves are removed, in others they are permitted to remain. Having passed these nerves the mass

is turned back into its normal position and severed from the body of the patient by a stroke of the knife from b to c, repeating the first cut through the skin. Every bleeding point, however small, is tied with fine silk, from 60 to 100 ligatures, or even more, may be required.

After the completion of the operation the wound into the axilla is closed with a subcuticular stitch of silver wire; if a cut has been carried above the clavicle, it is closed in the same manner, and the edges of the elliptical opening are brought nearer together by a purse-string subcuticular stitch. Thiersch grafts cut from the patient's thigh are used to cover the gap. Silver foil is placed over the wound, this is covered with gauze, bandages are applied, and the dressing is overlaid by a plaster-of-Paris bandage, which includes the head, neck, chest, and arm. The area from which grafts were taken is dressed with sterile gauze or an ointment containing boric acid.

XXXIX. SKIAGRAPHY, OR THE EMPLOYMENT OF THE RÖNTGEN RAYS.

The cathode rays were discovered by Hittorf, in 1869, while passing an induction current through a vacuum-tube. Crookes of London greatly improved the vacuum-tube, and obtained a rarefaction which left in the tube but the onemillionth of an atmosphere. This last-named observer found that when an interrupted current of high potential is passed through a vacuum which is nearly perfect, fluorescence takes place. In a Crookes tube the positive electrode is placed at some indifferent point, and the current from the negative electrode flows not to the positive, but directly to the wall of the tube opposite the cathode, and at this point the phosphorescent glow is detected.

In 1895, Röntgen of Würzburg, while making a study of cathode rays as developed in Crookes's tubes, discovered the energy which he named the X-rays. Röntgen showed that at the wall of the Crookes tube opposite the negative electrode a new and hitherto unknown energy is generated. Because of the uncertain character of this energy he gave to its manifestation the name of the X or unknown

rays.

The X-rays are invisible; cannot be deflected, reflected, refracted, or concentrated; are not influenced by the magnet; and produce none of the ordinarily recognized effects of heat. They cause fluorescence in certain substances, notably in tungstate of calcium (Edison), platinocyanid of

barium (Röntgen), and platinocyanid of potassium. They have a marvellous power of penetration, and pass through many substances which are opaque to sunlight, ultraviolet light, and ordinary electric light. They are readily transmitted by water, organic substances, leather, cloth, paper, and flesh. Bone transmits them less easily, and metal still less easily, but no substance absolutely prevents their transmission. An ordinary dry photographic plate is sensitive to the rays. If the rays are intercepted by a body not readily permeable which is placed between the Crookes tube and the photographic plate, a shadow will be cast, and a picture of this shadow will be formed upon the plate. Such a picture is known as a skiagraph or radiograph. If a body more or less resistant to the rays is placed between the tube and a fluorescent screen, the body casts a shadow on the screen, and the portion of the screen free from shadow glows with fluorescence. Such a screen is known as a fluoroscope.

It will thus be seen that the Xrays enable the surgeon to look beneath the skin and to see those things which before the discovery of Röntgen were unseeable during life.'

The real nature of the X-rays is unknown. They are not heat-rays; they are not ultraviolet rays. Röntgen thinks they are longitudinal ether-waves. Monell says, "They appear to be originated at the site of the greatest electrical activity within the tube, and their real nature is as unknown as the nature of heat, gravity, electricity, mind, and of life itself."

To obtain the rays a good apparatus is essential. An ordinary medical battery is incapable of producing them, as it is absolutely necessary to have a current of high tension. The discoverer used a Ruhmkorff coil, but this is by no means the most satisfactory apparatus to employ. Some experimenters have made use of a “powerful static machine and transformer coils" (Monell). Swinton uses twelve half-gallon Leyden jars and discharges them through the primary coil, the secondary circuit being a Tesla oil coil.

The current is best taken from the street-light circuit. Monell says that this current should be controlled by an interrupter, the interruptions of which are 100 per second. The interrupted current is to be passed into an induction coil, and the secondary current is to be conveyed into the Crookes

1 See Röntgen's report to the Physico-Medical Society of Würzburg, Dec., 1895; also the article upon the X-rays by S. H. Monell, in the Brooklyn Medical Journal, May, 1896.

tube by two wires. The secondary current thus produced will furnish a spark five or six inches long.

When the surgeon is about to use the X-rays, he must remove from the person of the individual anything that might cause confusion or lead to error. If the foot is to be examined, remove the shoes, because shoes contain nails; if the hand is to be examined, remove the gloves if they are fastened with buttons of bone or metal; if the thigh is to be examined, remove coins, keys, knives, etc., from the pocket; a garter, if it has a metal clasp, should be taken off.

In order to get the best results from the Röntgen rays, not only must the apparatus be good, but the man who uses it must be expert. Pictures taken by an unskilled man lack clearness of outline, and may even lead to positively erroneous conclusions. Nevertheless, a person used to the employment of scientific apparatus can very soon become sufficiently expert to take fairly clear pictures which should not lead to error. Morris H. Richardson' maintains that the Röntgen rays can be employed successfully in the routine office practice of a general practitioner.

The surgeon may utilize the X-rays by means of a fluoroscope. Edison's fluoroscope consists of four sides of a box, one end being open and made to fit tightly over the observer's eyes, the other end being closed with cardboard made fluorescent by smearing it with mucilage, and, before the mucilage is quite dry, sprinkling it with crystals of tungstate of calcium. If it is desired to examine the hand with a fluoroscope, the extremity is held opposite an excited Crookes tube and from six to ten inches away from it, the end of the fluoroscope which is covered with fluorescent paper is placed near the surface of the hand which is away from the tube, and the observer looks through the other end of the instrument. The flesh seems but a dim haze and the shadows of the bones are distinctly outlined. The fluoroscope can be easily used, and gives reliable results in studies upon the hands and feet, but when deeper structures are to be investigated, or when absolute accuracy is essential, it is better to take a skiagraph. The value of fluoroscopy is constantly increasing as better electrical appliances and Crookes's tubes are being made.

If thick tissues require to be penetrated by the rays, if great accuracy is necessary, or if a permanent record is to be retained, a skiagraph must be taken. In taking these pictures dry plates can be used; the plate need not be re

1 Medical News, Dec., 1896.