Of the Amputation of the Cancer'd and Scirrhous BREAST.
THE Success of this Operation is exceedingly precarious, from the great Disposition there is in the Constitution after an Amputation, to form a new Cancer in the Wound, or some other Part of the Body. When a Scirrhus has admitted of a long Delay before the Operation, the Patient seems to have a better Prospect of Cure without danger of a Relapse, than when it has increased very fast, and with acute Pain. I cannot however be quite positive in this judgment, but upon looking round amongst those I know who have recovered, find the Observation so far well-grounded. There are some Surgeons, so disheartened by the Ill-success of this Operation, that they decry it in every Case, and even recommend certain Death to their Patients, rather than a Trial, upon the Supposition it never relieves; but the Instances, where Life and Health have been preserved by it, are sufficiently numerous, to warrant the Recommendation of it.
The Scirrhus may be distinguished, by its want of Inflammation in the Skin, its Smoothness and Slipperiness deep in the Breast, and generally, by its pricking Pain, which as it is more or less, increases the Danger accordingly; tho' there are some few with little or none in the Beginning. As the Tumour degenerates into a Cancer, which is the worst Degree of Scirrhus, it becomes unequal and livid, and the Vessels growing varicous, at last ulcerates.
In extirpating the Scirrhus, if it be small, a longitudinal Incision will dilate sufficiently for the Operation, but if too large to be dissected out in that manner, an oval Piece of Skin must be cut thro' first, the Size of which is to be proportioned to that of the Tumour; for example, if the Swelling is five Inches long, and three broad, the oval Piece of Skin cut away must be nearly of the same Length, and about an Inch and a half in Breadth. In taking off the whole Breast, the Skin may be very much preserved, by making the Wound of it a great deal less than the Basis of the Breast, which must be carefully cleared away from the Pectoral Muscle: This is not difficult to do, because all these Scirrhuses being enlarged Glands, are encompassed with their proper Membranes, which make them quite distinct from the neighbouring Parts, and easily separable; at least this is the Case, when the Tumour is moveable; for sometimes it adheres to the subjacent Muscle, and that Muscle to the Ribs; in which Circumstance, the Operation is impracticable. When it is attended with Knots in the Armpit, no Service can be done by Amputation, unless the Knots be taken away; for there is no sort of Dependance to be laid on their subsiding, by the Discharge of the Wound of the Breast: The Possibility of extirpating these Knots, without wounding the great Vessels, is very much questioned by Surgeons; but I have often done it, when they have been loose, and distinct.
The Bleeding of the large Arteries is to be stopped by passing the Needle twice through the Flesh, almost round every Vessel, and tying upon it, which will necessarily include it in the Ligature. In order to discover the Orifices of the Vessels, the Wound must be cleaned with a Spunge wrung out of warm Water.
The scirrhous Tumours which appear about the lower Jaw, are generally speaking scrophulous Disorders, that distinguish themselves almost by the Circumstance of fixing on the Salivary Glands. These are very stubborn of cure, but not so bad as the Scirrhus, since they frequently suppurate, and heal afterwards: If they impostumate again after healing, 'tis for want of a good Bottom, which may sometimes be procured by destroying their bad Surface with a Caustick. Besides these, there is another Species of Scirrhus in the Neck, that succeeds better after Extirpation than either of the former kinds; this is an Enlargement of the Lymphatick Glands, which run close up by the Jugular Vein, and is distinguishable from Cancers of this Part, by its Moveableness, want of Pain, the Laxness of the Skin covering it, the small Degree of Pressure it makes on the OEsophagus and Trachea; and lastly the good Habit of Body, as it seldom affects the Constitution, which Cancers here do very early, after their first Appearance. This Tumour, from its Situation, requires great Exactness in the cutting off: the last I took away of this kind, I separated from the jugular Vein near the length of an Inch and a half: they sometimes extend up to the Chin towards the Mouth, and occasion a Division of the Salivary Duct in operating, which proves very troublesome to heal, but when all other Methods have failed, may be cured by a Perforation into the Mouth, through that Part of the Check where it is wounded, which by a Tent or small Seton may be made fistulous; then by properly dressing upon the Outside, the Oozing of the Saliva that Way will be prevented, and the external Orifice healed without Difficulty.
The Treatment of all these Wounds may be with dry Lint first, and afterwards as in the common incised Wounds.