If one is in the habit of doing such operations often, he soon learns always to follow a certain method. After cutting through the fascia cov ering the axilllity glands and fat, I usually immediately loosen all theist and the glands up to the large vessels and nerves, and then proceed back wards and downwards with the operation. In this way the axillary vein is laid bare, as a rule, and usually at the point of entrance of the thoracic vein; if the latter can be ligated at about I inches from its entrance into the axillary vein, this should be done; it is not advisable to tie it closer than this, because in case of suppuration the short portion easily becomes necrotic, and dangerous secondary hemorrhage may result. In the cases in which the ligation cannot be done at the length mentioned, I would advise the ligation of the trunk of the axillary vein above and below the entrance of the thoracic vein, and its division between the two ligatures. Ligation of the axillary vein causes far less disturbance of the circulatory system of the arm than would at first be thought. I have performed the operation very often, and only rarely have I seen oedema of the arm from it. In the cases in which there is considerable indurated cedetna in car cinoma of the axillary and supra-clavicular glands, many more veins than the axillary must be compressed, or the compression must be much higher than the axilla. In purulent decomposition in the axilla, extensive for. 'nation of thrombi, softening of the thrombi, emboli in the lungs, and the characteristic symptoms of pymmia may result. I cannot sufficiently advise against the use of styptics in these operations; we must search for and tie bleeding vessels, until bleeding ceases. We seldom come in con flict with the axillary artery in these operations; if it be closely adherent to the infiltrated carcinomatous tissue, we must perform a double ligation and extirpate the diseased portion. As a rule, gangrene does not follow simple ligation of an axillary artery and vein, but it might probably when the nerves are laid bare at the same time to a considerable extent. Only once, in the case of a girl, nine years old, have I extirpated the axil lary artery, vein and portions from all the nerve-trunks, on account of a medullary lympho-sarcoma in the axilla; the arm did not become gan grenous, but ulcers appeared on it on the least compression, which were only cured after a long time by the most careful treatment.
That an expert operator can attempt more, and do it quicker and with less loss of blood, than one who only exceptionally does such an operation, is of course understood.
Dressing and After-Treatment.—Formerly we were chary in uniting these wounds. As a rule, so much skin was cut away from over the mamma, that union was not to be thought of without modern therapeutic means, and the wounds in the axilla were not united on principle, so as the more certainly to avoid retention of secretion (so-called burrowing of pus), since this was the principal cause of extensive septic phlegmons, secondary hemorrhage, erysipelas and pysemia. There is probably no doubt at all that, of all the methods hitherto employed in the treatment of wounds, the antiseptic method has earned the preference; it seems to give comparatively the most certain prophylaxis against the accidental diseases of wounds, to which formerly, and especially in operations in robing the axillary space, so many patients fell a sacrifice. Therefore it cannot be recommended too strongly, that these operations should always be performed with strict antiseptic precautions, and particularly with those modifications of it in which the operator is most expert. As it is
beyond the limits of the present discussion to speak generally of the an tiseptic method, I will only call attention to those points which seem to me most important in the amputation of the mamma and the cleansing out of the axilla.
In order to obtain union of the wound, wholly or in the greatest part, after amputation of the mamma, when almost all the skin over the mam ma is removed, I cannot sufficiently recommend the use of a few button sutures (silver wires, with lead plates, fixed with shot). When the skin has been approximated closely in this way, the usual sutures are inserted. It is astonishing under how great tension (fixation of the thorax and arms after the operation being presupposed) primary union will take place. But we must not be betrayed into taking away too little skin in amputation of the mamma for carcinoma, in order to get more rapid heal ing. If it is impossible to unite the whole wound, so much as is possible is united at the sides, the wound is drawn together as much as possible by button-sutures, and the fresh wound, where it is not united, is covered with protective and Lister's dressing.
Recently, after cleaning out the axilla, I have always united the wound, after it had been carefully drained. I have found it a good plan to trans fix the soft parts below and behind (the deepest part of the wound with the patient lying on the bed) and put in a thick drain; besides this, three drains are put in above, the situation and patency of which are exactly known after closure of the wound. By putting two or three button sutures, the cavity of the wound in the axilla can be diminished to one fourth its size; the edges of the wound are then closed by sutures as usual. Compression of the axillary cavity with the dressing, by means of curled gauze is very useful. The antiseptic dressing should be as extensive as possible, surrounding the arm, fixed to the thorax, the whole thorax to the neck, and should extend below to the twelfth rib, and be fixed by oiled silk bandages. If, after its completion with the patient in the sit ting position, the dressing gapes below when the patient lies down, the gaps are to be filled with salicylic jute.
The danger of the operation is extraordinarily diminished by the anti septic method. I have often allowed my assistants to do these operations, because they teach a great deal about the technique of operating and dressing. Until the year 1877, I operated and dressed, with a few ex ceptions, mostly abortive cases of antiseptic dressing, according to the old methods (application of charpie, etc.). Of 305 such operations (in private and hospital practice), 15.7 per cent. terminated fatally, and in fact 6.7 per cent, were cases in which the mamma alone was operated upon, against 21.3 per cent. of the cases in which the mamma and axillary gland were operated upon at the same time, or the latter alone removed (for infection recurrences). Since January 1, 1877, until the present time (August 1, 1879), I have operated exclusively according to the antiseptic method Of 68 operations (in hospital and private practice) only 4 or 5.8 per cent. have resulted fatally, 0.0 per cent. of the operations on the mamma alone, and 10.5 per cent. of extirpations of both mamma and axillary glands, or of the latter alone. In one case death was due to pri mary hemorrhage occurring on the evening of the operation, and in three cases it was due to sepsis.