There are two points that I should like to emphasize in the treatment of cases in which the parotid is involved secondarily: first, the importance of regular oral hygiene, instructing the nurse to follow out cleansing of the mouth and teeth with as much regularity as administering of the diet and medicine, and, second, the importance of making an early incision and drainage. The abcesses. are deep-seated beneath the fascia; and, consequently, fluctuation is very seldom obtained. It is, of course, better, if possible, to wait until fluctuation can be obtained; but it is important, in my opinion, to practice early incision and drainage.

DR. GEORGE BLUMER (New Haven): I have not much to add, but I simply wish to point out the tremendous difference in the prevalence of secondary parotitis in a disease like typhoid fever since trained nurses have been in use. This is favorable to the view that it is an ascending infection through Stensen's duct. One other fact that has been mentioned is that with very sick patients there is a reduction of the general resistance to bacteria. So far as the dry mouth is concerned, there is pretty good evidence that this is not always an important factor; because there is a disease called dry mouth in which there is usually no parotitis. There is a total lack of secretion from all the salivary glands, yet the patients do not usually contract parotitis. This disease is possibly a little atypical because the conditions necessary for the multiplication of bacteria are not present; so I should not like to say that temporary absence of secretion of the parotid gland is not an important factor. It seems to me, however, that the evidence of an ascending infection from the mouth, in the vast majority of cases, is very strong.

SURGICAL PAPERS.

The Importance of Early Operations for Tumors

of the Breast.

GEORGE N. BELL, M.D., HARTFORD.

Not very long ago, in looking over a "System of Surgery," published in Edinboro in 1784, I came across a chapter devoted to Cancer of the Breast, from which I will quote:

"A real cancer is perhaps the most formidable disease to which the human body is liable: Wherever it may be situated, its consequences are to be dreaded: but more especially when seated on the mammæ.

"We have elsewhere shown, that cancer, on its first appearance, is perhaps, in every instance, a local affection only: that the cancerous diathesis is produced, not by any original affection in the constitution, but by absorption from a local ulcer; and hence we concluded, that every cancerous sore should be removed by immediate amputation, wherever this can be practised.

"This, we think, ought to be an established maxim in the treatment of all cases of cancer wherever they are situated; but from their being, as we have said, more apt to infect the general system, when seated on the mammæ, than on other parts of the body, this is an additional reason for early amputation in every cancerous affection of the breast.

"As every schirrous gland in this part is apt to degenerate into real cancer, and as indurations of this nature have hitherto resisted the effects of every other remedy, we should on every occasion advise their removal by early amputation: This, we know, is a point with respect to which practitioners are not universally agreed; as it is alleged by some, that scirrhous glands in the mammæ have been known to remain in an indolent, inoffensive state for a great length of time; and therefore, that their removal ought never to be attempted till they have actually proceeded to a state of ulceration.

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"But this opinion, which is evidently founded in timidity, has been the cause of much unnecessary distress to such individuals as have followed it; and has brought the operation of amputating cancerous breasts into a degree of general discredit which it does not merit. There is no fact of which I am more convinced, than that many more would recover by means of the operation were it employed in a more early period of the disease."

So it appears that the situation in regard to breast tumors has not changed much in the past century. We have made great strides in anæsthesia, in operative technique and in after-treatment, but in diagnosis and in early radical work we are still lacking.

Of all cases seen by the surgeon probably there is no class which carries with it a greater weight of responsibility, and the final disposition of which has such far reaching consequences as tumors of the breast, because we must not only give an opinion as to the nature of the tumor, and the advisability of operation, but must pass upon the extent of that operation and the prognosis both with and without operation. In giving this opinion we must weigh carefully in our minds the size and position of the tumor, the age of the patient, the length of time the tumor has been noticed, its motility, its glandular involvement—if there be any, compare in our minds with previous cases, recall statistics, and try to come to some decision as to its character.

In the beginning of this paper I wish to emphasize one thing that we should get firmly fixed in our minds along with many others of greater or lesser importance, that is, that all breast tumors can be roughly divided into two great classes, benign and malignant. I shall not go into the pathological classification of tumors at all, because so far as the patient or the surgeon is concerned there are no border-line ones. The benign,-if we can be absolutely sure, and note that-absolutely sure, of their benignity are to be left alone, and the malignant are to be removed. There can be no other way, and the whole question of diagnosis and removal of breast tumors depends upon our ability to decide which is which. We can only bring to this question the opinions and experiences of many operators and