CANCER OF THE BREAST.—The only justifiable procedure is the entire removal en bloc of the whole gland, with its skin and surrounding fatty tissue, both pectoral muscles, or the greater portion of each, the muscular aponeurosis and the axillary glands; the supraclavicular lymphatics, when these latter are found to be involved, must also be removed.
Broadly speaking, there are two methods of attacking this operation: (i) Rodman's. This consists in beginning at the apex of the axilla, clearing the latter completely, and then dealing with the breast. (2) Hal stead, Handley, and others begin by removal of the breast itself, tracing upwards the lymphatic vessels and removing the contents of the axilla last.
The preliminary incision and the various steps of this radical operation may be modified according to the dimensions of the diseased gland and the practice of the operator. The usual skin incision is one commencing about the middle of the clavicle, with the arm abducted and extending across the anterior fold of the armpit into the axilla, and at a later stage continued so as to remove a large oval of skin overlying the gland and finally ending below the costal arch as far as the line of the sternum.
The dissection of the mass from the apex of the axilla (the insertions of both pectoral muscles having been divided) is commenced, everything being removed, including the fascia of the serrates magnus, and the axillary vein exposed for its entire course. In like manner the origins of both pectoral muscles are cut and the fascia dissected from the surface of the lower ribs. sternum and the upper part of the rectus and external oblique, after which the entire mass is separated and removed in one piece; it should contain all the tissues between the subcutaneous fat and the ribs, and extending from across the middle line to the apex of the axilla and the axillary border of the scapula.
The removal of the glands above the clavicle in the triangle bounded by the clavicle, trapezius and sterno-mastoid must be effected when any sign of infiltration of these is found; by altering the position of the arm this can usually be accomplished without division of the clavicle.
Drainage is provided by the insertion of a tube pushed up into the apex of the axilla, its lower end left projecting from a buttonhole at the scapular angle and a moderately tight bandage being applied to the thorax over the dressings; the unbandaged arm is abducted and supported upon a pillow.
The mortality of this formidable operation is almost nil, and a fairly useful arm results, though (edema may remain for a considerable time owing to injury of the axillary vein. The results are incomparably better than those obtained by the older and now abandoned plan of merely excising the mammary gland, and in a fair percentage of cases no return of the disease follows; when this does occur, the carcinoma appears in the hones, pleura or internal organs, and seldom in the scar tissue. The practice of following up the operation by the use of the X rays as a prophy lactic against recurrence is gaining favour.
In inoperable mammary cancer relief may be obtained by local and general anodynes, the use of the X rays and antiseptics when ulceration has occurred. The progress of the disease is retarded by removal of the ovaries, but this is contra-indicated when the climacteric has been reached.