When such radical measures are not required, and a simpler operation is war ranted by the limits of the tumor, the following procedure may suffice: The breast is carefully asepticized by wash ing, and bathed with a mercuric-bichlo ride solution, and the axilla is shaved and treated in the same manner. An in cision is then made, also from the axilla, but anterior to it, extending downward and around the tumor, the latter being included in the ellipse formed, and meeting the starting-point. Even if the growth be exceedingly small, a wide mar gin should be removed with all suspected tissue. The knife should penetrate clear down to the muscular aponeurosis, from which the mass can easily be detached; but if the aponeurosis is adherent it must be removed. If any muscular fibres also show adhesions, the Halsted operation should be resorted to. The vessels should be rapidly caught to avoid luemorrhage as the case proceeds.
Examination of the axillary ganglia is warranted in all cases, and their careful dissection is always indicated, when there is the least suspicion that they may be involved. They are unmistakably so in Over 60 per cent. of cases. The wound is then to be carefully washed with a bi chloride solution, after carefully arrest ing all the bleeding vessels. The anti septic solutions used should be luke warm, to prevent chill, the operation be ing rapidly performed in a warm room for the same reason. The two edges of the wound should then be sutured, after having placed a drain at each end of the wound. The whole should then be dusted with iodoform, and covered with a thick layer of antiseptic absorbent cotton, held in position by a broad band age tightly fastened around the chest. When antiseptic precautions have been carefully carried out, union takes place at once. The dressing should not be re moved until the third or fourth day, to remove the drains and sutures. These should be replaced by strips of linen im pregnated with iodoform collodion.
When the breast has been removed it is important to ascertain whether any cancerous tissue has been left. This is ascertainable at least as far as the tissues through which the incision has passed, by means of the proceeding recom mended by Stiles, of Edinburgh. He gives the steps of the procedure as fol lows: "1. Mark the position of the breast by a slight incision extending both on the breast and on the skin which is to be left. This is to enable the oper ator to identify the position, and there fore the corresponding surfaces of the breast and the wound after the removal of the breast. 2. Wash the breast in water to remove all traces of blood. This is important, because after treat ment with nitric acid the blood becomes blackened and difficult to remove, and therefore greatly obscures the appear ances which the acid brings out. 3. Sub merge the whole organ in a 5-per-cent. aqueous solution of nitric acid (B. P.) for about ten minutes; that is to say, during the time the surgeon is clearing out the axilla. 4. Wash in plenty of running water for five minutes. 5. Place in methylated spirit (undiluted) for two or three minutes. 6. Examine the whole surface very carefully to ascertain (a) whether any part of the tumor is ex posed upon the surface, (b) whether any locally-disseminated cancer-foci are exposed upon the cut surface, or (c) rvhether breast-tissue is exposed."
All the cancerous tissues treated in this manner are rendered a dull, opaque white, indicating that more tissue must be removed from the corresponding spots in the wound.
When the growth cannot be removed, palliative measures must be adopted. The organ must be relieved of all press ure, and the movements of the cor responding arm restricted as much as possible. The use of morphine and atro pine hypodermically in such cases is fully warranted, the object being to cur tail suffering, even if very large doses have gradually to be reached. Locally, boric acid, directed over the growth, or a solution of acetate of lead, 20 grains to the ounce, sprayed over it, are useful procedures. Local applications of solu tions of the extract of opium or bella donna sometimes quiet the suffering.
Bernart recommends, as a curative measure in inoperable cases, interstitial injections of a solution of salicylic acid, 15 minims to 1 drachm of a 6-per-cent. alcoholic solution being used after strict antisepsis. From 10 to 15 injections are said to produce considerable alleviation.
Ilasse, of has used injec tions of alcohol for more than 20 years in the treatment of inoperable cancer, and 4 cases of this kind in his prac tice are now cured. He uses the same method in cancer of the breast, and be lieves that cure could be effected in these cases by surrounding the breast with cicatricial tissue by means of alco hol injections. It is preferable, however, to extirpate the breast and treat recur rences by the injections. In this man ner he obtained radical cure in a case declared inoperable by Volkmann. Vul liet, of Geneva; Kuh, of Chicago; Young, of Bloomington; and others have also obtained good results from this method. Hassel used alcohol diluted one-half, or even more with very sensi tive patients, having found it less pain ful, while equally effective. One, or at most two, injections are made at a time, drawing the breast out and inserting the needle in such a manner as to cause the alcohol to penetrate into the retromam mary cellular tissue beyond the middle of the gland. The contents of the syringe should flow out gradually on gentle pressure of the piston. If there is resistance it should be withdrawn a little and the point inserted sidewise in another direction. In this way the retro mammary space is filled with the alcohol, 4 to 10 cubic centimetres for small tumors and 10 to 20 cubic centimetres for larger ones. One must be careful to keep well in the space behind the tumor. After the needle is first introduced it should be withdrawn to see if any blood flows out of the needle-hole, showing that the needle has penetrated a blood vessel. If it has, the syringe must be cleansed and inserted in another place. The injections are made once or twice a week at first, and then later once in two or three weeks. These injections are, unfortunately, rather painful. Another method which has, of late, afforded en couraging results is the use of the Roentgen rays.