Ordinarily the lymphatics on the upper and lower surfaces of the breast empty into three lymph vessels for each set, and these unite in emptying into the axillary ganglion. It is possible, however, that one or both of these sets of vessels turn under the outer margins of the pectoralis and unite with the axillary lymph vessels in the infra-clavicular instead of in the axillary region. If this is true, and my experience leads me to believe that it is true, then any operation short of a complete cleaning out of the infra-clavicular space is incomplete, and will almost certainly result in a prompt recurrence.

If we accept the theory advanced in the beginning of this paper that cancer is due to a parasite and infectious, then it is probably from an auto-infection that many of the recurrences result.

If we do believe this, then I believe that the Halsted technique is incorrect, for if we operate upon the breast first and then attack the axilla, the necessary manipulation of the detached breast must press the parasite onwards through the lymphatic vessels to uninfected regions. In order to avoid this the operation should be reversed. Cut off first the abundant lymphatic current running from the breast and the surrounding tissues to the root of the neck. In order to do this we should begin in the axilla with an incision running along the anterior border of the axillary space and along the humeral margin of the pectoralis major until by reflecting the skin, with only enough fat not to disturb its nutrition, we can expose the whole axillary space. The axillary vein is then exposed at the apex of the axillary triangle and the fat and glands carefully dissected away from it. As soon as the margin of the pectoralis is reached the skin over the muscle is dissected upwards until the humeral attachment is exposed. This is then cut away close to the humerus and the skin incision is carried down to make the upper incision for the removal of the breast. This upper skin flap is then dissected upwards and inwards until the sternal and clavicular attachments of the pectoralis major muscle are exposed. The clavicular attachments are then cut away and all the fat and fascia lying over the pectoralis minor is taken up with it; while this muscle is drawn down, the skin flap is drawn up and the pectoralis minor cut through at about its middle. The upper portion of the muscle is then drawn up with the skin flap, and the fat and glands and fascia connected with the axilla and in the infraclavicular space is dissected away. The posterior portion of the axilla is then cleared away, taking care to save, if possible, the subscapular nerves. The lower skin incision is then made and the whole mass of glands, muscles, fat, breast and fascia are removed "en masse." It may be well, if the patient's condition is still good, to clean out the supraclavicular glands, but in order to do this the operation should not be prolonged beyond the limit of safety. Some operators have advocated an immediate skin graft, but that also takes some time and adds to the shock of an already extensive operative procedure. This is made necessary because of the large amount of skin that all operators believe should be removed with the growth. I am convinced, however, that it is better to draw the skin together as much as possible by means of sutures, even though some sloughing of flaps does result, because the remaining ulcer is much reduced in size by that procedure. It then becomes a simp'e matter to do a secondary skin graft two or three weeks later if it is necessary. Drainage should always be employed in the axillary space and also in the infra-clavicular space, as the removal of so much tissue leaves hollows that are sure to fill up with serum and blood which will otherwise have to be evacuated.

Before uniting the skin the pectoralis minor muscle is united by sutures. The after usefulness of the arm is but little curtailed by this operation. It is remarkable how well patients can get along without the pectoral muscle, but they must be encouraged to exercise the arm freely as soon as the wound is sufficiently healed. In closing the skin care should be taken not to have any tension on the skin in the axilla in order to avoid cicatricial contraction and pressure upon the axillary vessels.

In my opinion every tumor of the breast should be removed as soon as possible, and time should not be wasted in vain attempts to absorb it. If there is reason to believe that the growth is benign it may be cut into first and then the operator may determine whether it is suspicious or not. But every suspicious tumor of the breast should lead to a complete extirpation of the breast at once. Age is no protection from cancer, and we should not forget that it may appear in early as well as in late life.

I have operated for cancer, and the pathological report has sustained the diagnosis, in a woman of twenty-six and in several between that age and thirty.

If cancer is infectious we should warn the patient of that fact, and all dressing and everything coming in contact with the disease should be destroyed by fire.

THE DOCTOR'S SCAPEGOAT-THE LIVER.

BY E. R. ANTHONY, M.D., GRIFFIN, GA.

We all know that it is gratuitously assumed and charged by the public generally, that when the doctor does not know where to lay the blame for ills that cry aloud for help in man, he places them upon the liver.

For his sins of ignorance of pathology and diagnosis he makes a scapegoat of the liver, and with a dose of calomel and soda turns it loose to make its way into the wilderness of results.

The truly scientific man, however, knows that a large percentage of all the diseases, the aches and pains with which the general practitioner meets, is due to a disturbance of the functions of the liver. If we could give pre-eminence to any organ of the body where so many are essential, we would name the liver, because of its varied and important duties.

The liver is both a secretory and an excretory organ, for it elaborates materials for serving some ulterior office in the body, as well as those which are to be excreted as useless and injurious. The liver may be called the health officer of the body, and nobly does it perform its duties. Placed at the gate of the great highway by which the greater part of all the materials absorbed from the intestinal tract reaches the blood, it stands a tireless watcher, a sleepless sentinel, and inspects every drop of blood on its return trip to the heart, to see that it contains nothing that is a menace and a threat to good health.

The liver may also be called a great commissariat, because it not only elaborates glycogen, but it acts as a storehouse for this important carbohydrate, which is not only essential for the nourishment of the tissues, but is one of the great factors of potential energy ready to be converted into kinetic energy whenever necessity demands. The liver may also be called the great State Chemist, that, in the laboratory of its hepatic cells, is constantly making both analyses and syntheses essential to life. This is seen in its manufacture of urea, bile acids and bile salts, and so long as disturbed nutrition is so generally dependent upon deficient excretion, so long will the action of the liver in the chemistry of the vital processes be considered all-important. A liver that is not performing all these important functions as it should, therefore becomes a protean monster in the causation of disease, not of the body alone, but as alienists tell us, of the mind also. Its influence on the mind, even on man's highest aspirations, his hopes, his fears, is illustrated by the fact that people who are dying of liver disease are apt to be despondent in view of eternity. The oculist, the gynecologist, in fact all the specialists, recognize and acknowledge the fact that a great many diseases they are called upon to treat arise from a disturbance of the functions of the liver.

The design of this paper is to discuss briefly these important functions of the liver. No attempt whatever will be made to exhaust the topic, and I fear very little that is new or original will be said. But the writer hopes that the paper will at least be timely, because of the fact that the members of our profession, in their enthusiastic search for bacteria as a causation of disease, seem to have forgotten our old friend, the liver, and the important rôle it plays in the causation of sickness when its functions are disturbed. much is said and written nowadays about infection and in

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