OPERATION. — The most promising procedure is that of Halsted, who con tends that the pectoralis-major muscle entire, except its clavicular portion, should be excised in every case of cancer of the breast, because the operator is en abled thereby to remove in one piece all of the suspected tissues. J. Collins War ren also emphasizes the importance of thorough removal of all suspicious tis sues, including a large margin of the cutaneous covering of the breast, a care ful deflection of the edges of the wound, removal of the subcutaneous fat for a considerable distance around the mam mary gland, the removal of the pectoral muscles, and a minute and painstaking dissection around the sheath of the ax illary vessels. Arbuthnot Lane also re moves the pectorals, carefully dissects away every particle of glandular and areolar tissue from the axilla; also, if necessary, dividing the clavicle, and clearing out the subclavian triangle if need be.
What such thorough work affords in results is well illustrated in J. Collins Warren's report, in which 22 cases oper ated upon under the improved technique gave S cases cured, a percentage of 36 per cent.; all cases in which re currence had not taken place had not oc curred at the end of three years.
Three years ago 61 cases operated upon at periods varying from one month to six years were described; in 21 of these from three to six years had then elapsed since the date of the operation. From three to nine years have now elapsed since these 61 cases were operated upon. Their present condition, as far as it has been possible to ascertain, is: Of the 61 patients 30 remain free from recurrence.
Further list of 33 patients operated upon up to the end of 1897. In these from one to three years have elapsed since the operation: 26 patients re mained well without recurrence; one re fuses to say how she is, hut appears well; in 1 the result is unknown; 1 died suddenly about a fortnight after the operation; 7 died of recurrence; 1 recurred and has probably died; in 1 the disease recurred slightly, has been operated upon, and appears well.
In the total of 99 cases above, in which from one to nine years have elapsed since the operation, 56 certainly have as yet had no recurrence.
Conviction that about 50 per cent. of all cases of cancer of the breast will re cover from the operation and remain free from recurrence if the original procedure is drastic enough. Especially is it neces sary that the removal of the skin should be free. The patient's chance lies in the first operation. Watson Cheyne (Lancet, Mar. 18, '99).
The breast should first be carefully cleansed and asepticized as far as pos sible and the axilla shaved and treated in the same manner. The incision is then begun at the anterior axillary fold, and, describing an ellipse embracing the whole gland, is then brought back to the starting-point. The skin and fat of the
regions traversed should be penetrated down to the muscular tissues beneath, the organ being then detached from be low upward, i.e., progressing toward the axilla.
The supraclavicular region is almost invariably cleansed out by Halsted (Trans. Amer. Surg. Assoc., '9S) at this stage, and he found that removal of the supraclavicular fat and lymphatics is best done from within outward and from below upward. The subclavian vein be ing the starting-point in the dissection of both the infraclavicular and supra clavicular regions, it is unnecessary to remove the clavicle and useless to di vide it. By elevating the shoulder the clavicle can be raised an inch or more away from the first rib. The fingers can be pressed from the supraclavicular to the infraclavicular and to the subscapu lar regions under the clavicle, and any fat in the latter region, near the internal or the posterior border of the scapula be tween the serratus magnus and subscapu tar muscles, which could not be drawn out through the neck. To excise the su praclavicular tis,ues a vertical incision is used parallel with the sterno-cleido-mas toid muscle near its posterior border; a few of the posterior fibres of this muscle are divided and the junction of the inter nal jugular and subclavian veins is ex posed. At the angle of junction of these veins the dissection is begun. The omo hyoid is divided at its tendinous part, the two bellies of this muscle being drawn out of the way. The supra clavicular fossa is cleansed out or stripped, with very few exceptions, at the primary operation. The rule should be to operate on the neck in every case. The minor as well as the major pectoral muscle is removed; the insertion of the major, and then its origin and the origin of the minor being divided, before the subclavian vein is exposed, first at its inner part; and the axilla stripped of its contents and its anterior wall at one time from within outward and from above downward. The mass to be excised must always be circumscribed with a circular or an oval incision, and an additional cut made to expose axillary and jugular veins. The operation is performed in an absolutely bloodless manner. In all cases the wound is grafted immediately; this is done by cutting grafts from the patient's thigh as large as or larger than one's hand. A single one of these large grafts may be enough to cover the raw surface. In cutting a graft of this kind the skin is made tense by a board which the operator slides along the thigh just in front of a large amputating knife or catlin. The graft is spread, raw side up, on a piece of rubber tissue, and from the latter is readily transferred to the breast-wound. It is finally covered with silver foil and tissue-paper, and need not be looked at again for two or more weeks.