opened we saw clotted and liquid blood. The pelvis was full of it. A mass was seen in the right pelvis; this was covered with a gauze pad for the time being. Going on the left side of the patient, entering the abdominal cavity, passing two forefingers of my left hand through the foramen of Winslow at the junction of the cystic and common ducts, I felt this irregularly shaped stone. In trying to force it up into the gall bladder, it slipped away and went in the direction of the common duct. I went after it again, and pushed it into the gall bladder. Then incising the gall bladder at the site of the former wound which had closed, I slipped the stone out. I then demonstrated that the ducts were pervious by forcing water through them into the duodenum. Here, you see, is the fetus which measures three inches and a half from vertex to nates. Both fetus and placenta were found in the tube. The last operation was performed six weeks ago, and now you have the patient and speci

mens before you.

100 STATE STREET.

PLASTIC OPERATION FOLLOWING RECURRING CARCINOMA OF THE BREAST.

BY EMANUEL J. SENN, M. D., CHICAGO.

This patient is fifty-three years of age, and, as you will notice, is blessed with a very robust constitution, although she has been. suffering from carcinoma for the last two years. About two years ago she first noticed a swelling in the right mammary gland, which was diagnosed as cancer. An operation was performed and she remained free from the disease about one year, at the end of which time she noticed a recurrence of the growth in the scar. She tells me that she was again operated upon. The patient came under my observation last month. At the time I saw her and made an examination, I found an immovable mass in the breast, in the center of which was a sinus leading down to one of the ribs and indicating secondary infection. There was considerable discharge. I rather advised against operative interference, but when she insisted upon it and asked for a new lease of life, I operated. The first operation performed was the ordinary one usually resorted to in these cases, so far as I could determine at the time. You will notice two elliptical scars on either side of the cancerous mass. At this point there is a scar showing that an incision was made which extended Chicago Medical Society, November 2, 1898.

up into the axillary space, it being in the mid-line. At the time I examined her she was unable to lift the arm to any extent. I made a wide incision extending from the midsternal line and carried it in the direction of the axilla, removing the skin and tissues underneath to the ribs, where I found that the mass was attached to the ribs. The operation of thorocoplasty was indicated, but I did not favorably consider such a mutilating operation because it would have been entirely useless. I dissected off the mass from three or four ribs and removed all of the intercostal tissue. I then carried the incision up to the external border of the pectoralis major. The surgeon who performed the first operation had done it quite thoroughly, and carried his incision up into the axilla. I made an incision on the thoracic side of the axilla, much preferable to one in the middle line, resorted to digital palpation, but could find no glands at all, showing that the secondary involvement was not due to lymphatic extension, but must have taken place in the scar. The enormous area which was bared by the dissection had to be covered. The woman had a pendulous abdomen.

I took a piece of wet hygroscopic gauze and covered the raw wound surface, took an impression by means of the blood stain, and in this way I got some idea of the surface to be covered. I made a flap from the abdomen in accordance with the impression, twisted it upon its axis, and brought it in place. There was considerable tension at one point, I therefore mobilized the skin by undermining, and was able to cover the extensive wound very nicely. Knowing that the wound was already infected, I resorted to tubular drainage. I put one drain in the lower field of operation, and another under the axilla. One drain was removed at the end of twenty-four hours, and the other allowed to remain because there was a little parenchymatous oozing. There was so much tension of the skin in some parts that the skin was perfectly black or gangrenous in appearance. I expected the upper portion to slough away, but to my surprise there was no sloughing from that source. There was slight sloughing about half an inch in diameter in the lower part of the wound. I regard this partial sloughing as being due to pressure of the large drainage tube lying underneath, as removal of the tube was followed by definitive healing. It is now some five weeks since the operation was done, and the result is all that one could expect.

In regard to this incision, in doing amputation of the breast, when going up into the axilla, it is best to make an incision at the external border of the pectoralis major, for several reasons: First,

it gives direct access to the pectoralis fascia, which must be removed in all of these cases; second, it is the shortest route to the blood vessels; third, it marks the line of the axillary vein and you are enabled to reach this vein at its proximal point. When you find it, you can dissect away all the involved glands with safety, and you know where you are. The quickest way to reach it is to follow the external border of the pectoralis major muscle. One of the reasons why the patient could not lift her arm after her former operation was because of cicatricial contraction, following an incision in the mid-axillary line, a procedure which I only mention to condemn. This is not very marked at the present time, as I have dissected out the scar.

With reference to doing a mutilating operation in this case as a primary procedure, I think in all cases in which there is primary carcinoma of the mammary gland, where the disease appears superficial and is in close proximity to the nipple, we should do the work in accordance with the principles laid down by S. W. Gross, that is, removing a wide area of skin. If this is not. done we are almost sure to have a recurrence of the disease in a short time. In all cases in which the glandular structure near the skin is involved there is much greater liability of involvement of the superficial lymphatics and also of the pectoral fascia. This was shown by Heidenhain, who pointed out that the capsule of the mammary gland is thin and has a very close relationship with the pectoral fascia. Again, we must consider the so-called suspensory ligaments of Sir Astley Cooper. Heidenhain believes the ligaments coming out from the mammary gland are apt to be surrounded by prolongations of the parenchyma of the gland, therefore the great liability of the cancer cells following the line of least resistance along the suspensory ligaments. It was due to this that Halsted devised what is known as the Halsted operation. It was Heidenhain, however, who did the anatomical research in this region, but Dr. Halsted really gets the glory. It should be known as Heidenhain's operation rather than Halsted's.

100 STATE STREET.

CASE OF EXTEN SIVE FISTULA IN ANO AND RECTAL INCONTINENCE.

BY J. R. PENNINGTON, M. D., CHICAGO.

The first patient to whom I invite your attention this evening was referred to me by Dr. Flood about eighteen months ago. She was then suffering from what is commonly called a horse shoe

Schematic drawing of the fistula. The dotted lines F. represent the fistula and abscess cavity. The dark lines, L. I., line of incision. E. O. external opening. A. C., abscess cavity. I. S., internal sphincter. E. S., external sphincter. R. L., right labia. L. L., left labia. L. I. R. F., apex of left ischio-rectal fossa. Y., fistulous track passing under external sphincter into the bowel and not divided.

fistula. This fistula is frequently, though not always, preceded by an abscess situated between the rectum and coccyx and beneath the raphe. In a typical case the pus burrows on both sides of the rectum and into the bowel dorsally between the sphincters. Cripps says, "that the matter originally collects in one or other of the ischioChicago Medical Society, November 2, 1898.

rectal fossae, then makes its way behind the bowel to the fossa of the opposite side."

From inspection and examination it is often impossible to measure the gravity of a case of fistula in ano. One may not suspect its complexity and extent until after the first incision has been made. The presence of only one external opening does not necessarily signify a simple fistula. I have seen some very extensive and complex fistulae with only one external opening. That was the condition of affairs in this case.

In operating upon these cases it is important to recognize their conformation; especially is this true when there is one or more external openings on each side of the anus, and to bear in mind that these tracks have a home in common. Otherwise the operator is apt to proceed as though he had two separate and distinct fistulae with which to deal, and by following the advice given in some of our textbooks, slit up first one sinus, then the other, and when too late to remedy, recognize that he has divided the sphincter in two or more places, that his patient has incontinence of feces and a remaining fistula-a very undesirable result. I say undesirable, because to operate and not cure the patient is to bring disrepute on rectal surgery, and for the operation to be followed by incontinence of feces is to leave the patient in a most mortifying and loathsome condition, which is not apt to redound to the surgeon's credit.

In this patient there was an external opening in the right buttock and an internal one on the left aspect of the bowel. With reference to finding the internal opening when operating, Mathews says: "What this has to do with the operation for fistula, I must confess, I cannot understand." Then he continues by saying that "if during the operation I introduce my grooved director and fail to find any internal opening, when one really exists, I push the instrument through the mucous membrane, then divide the tissues upon it, and search up the bowel from the cut, allowing the director to go as high as it will. Then, dividing again, we of course include any internal opening that may exist." Had I followed this advice and pushed the director through the mucous membrane and divided the structures over it, incontinence would certainly have followed and the internal opening remained undivided. Beginning at the external opening I divided the fistulous tracks as indicated by the heavy lines. in the right buttock to a point just beyond the track, Y., running into the bowel. I then discovered this latter fistula, which I thoroughly curetted and irrigated with a bichloride solution. I purposely at this seance did not continue the division farther on the