THE COMPLETE METHOD 
Of Operation in Cases of 
GANGER OF THE BREfIST, 
DR. A. C. BERNAYS, 
SAINT LOUIS, MO. 
Abstract of a Clinical Lecture delivered at the 
Marion-Sims College of Medicine. 
Reprint from the- Courier of Medicine, January. IBi>s, AUGUSTUS CHARLES BERN AYS, M. B , M. D., (Heidelberg) M. R. C. S. 
Professor Anatomy and Surgical Pathology, Marion-Sims College of Medicine 
and Woman’s Medical College, St Louis. 
UNION TRUST BUILDING, SAINT LOUIS, MO 
HOURS FROM 11 to 1. 
REBEKEH HOSPITHL FROM 9 to 10. COMPLETE METHOD OF OPERATION IN CASES OF 
CANCER OF THE BREAST. 
By Prof. Augustus C. Bernays of St. Louis, Mo. 
Abstract of a Clinical Lecture delivered at the Marion-Sims 
College of Medicine. 
In the wonderful progress made in surgery under the regime of 
antisepsis and asepsis, one department of the art has not made the pro- 
gress which we originally expected to see. I refer to the treatment of 
malignant growths. Under the strictest antiseptic precautions it was a 
priori expected that the surgeon would be enabled to get much better 
results than in former years, because the operator could dare to go much 
farther in his extirpations of malignant growths. The assurance which 
we felt that the healing process would be afebrile and aseptic would per- 
mit of the most radical removal of all the diseased tissues. We should 
reasonably expect a much reduced percentage of recurrences under these 
circumstances than ever before. Judging from recent articles in the 
medical and surgical literature this expectation has not been realized, 
and I am sorry to notice the mo-t pessimistic views in the progress of 
cancer of the breast expressed by many surgeons. It is my object to 
COMBAT THIS VIEW AND TO URGE UPON THE PHYSICIAN AND GENERAL 
PRACTITIONERS THE NECESSITY OF A MOST AGGRESSIVE AND POSI- 
TIVE STAND WHEN CONFRONTED WITH A CASE OF MALIGNANT DISEASE, 
PARTICULARLY IN CASES OF CANCER OF THE BREAST. 
In doing thU 1 am enabled to lean upon the most excellent and en- 
couraging report from the Johns Hopkins Hospital which appeared in the 
latter part of 1894. and upon the results obtained in my own private and 
hospital work. My own views and practice, in fact, the operation which 
1 have been doing for over fifteen years, coincides with that described by 
Dr. William S. Halsted in the report just mentioned, almost in every 
detail. This surgeon has, however, rendered us a most valuable service 
by the clear and concise description of the steps of the operation. I think 
that by following his rules implicitly, even a surgeon whose work and 
material are limited, will be enabled to get results which will be most 
satisfactory, as compared to those which are reported by operators who 
perform the old slip-shod and much less painstaking methods of removing 
the cancerous breast. 
The three engravings which accompany this article will serve better 
than a lengthy description of the method of operating to elucidate and as- 3 
sist the busy practitioner ol medicine. 
I desire to quote two s< ntences from Dr. Halsted’s report: -Tn fifty 
cases operated upon by the complete method we have been able to trace 
only three local recurrence* ” Again, “1 have not had a local recurrence 
lor more than three years.” retel l ing of course only to cases where the 
complete operation was done. 
Now. let us see what we mean by the complete operation; in other 
words, what has been done in the operation which you have just wit- 
nessed? The lady is thirty-seven years of age, of a very nervous rganiza- 
tion, is married, has one child. There is no history ot cancer in any near 
relation. Tumor of right breast observed for over three years. The 
tumor is not freely movable over the pectoralis muscle. The nipple is 
retracted and indurated, and there is, as you see, a nodule on its outer 
side. There were some shooting pains at long intervals, the patient has 
complained very little of pain at anytime. The tumor is hard; size of a 
large orange, skin involved, but not broken. A chain of small, hard, 
glands, evidently carcinomatous, extends to the top of the axilla. 
The patient was prepared in the usual way with a view to sterilizing 4 
the skin over the field of the operation. Chloroform administered and 
the patient put into position upon the edge of the table, the arm being 
held up and extended by an assistant, whose sole duty it is to keep the 
limb in such a position as will aid the operator in his dissection. The 
long skin incision is made with a sweep of the knife around the breast, 
and as far up on the arm as the lower border of the teres major tendon. 
The costal and clavicular insertions of the pectoralis major mu-cle are 
now carefully cut oft and the muscle with the breast on its surface turned 
over under the arm. This is best done by the fingers and sometimes re- 
quires some (oice and tearing. The apex of the axilla is now exposed, 
and we can determine whether the glandular and lymphatic involvement 
will require the removal of the pectoralis minor muscle or not. If the 
sheath of this muscle is thickened or shows any infiltration along the 
vessels entering it, it must be wholly or partially removed. At this stage 
of the operation the condition of the infraclavicular glands and also those 
lying just above the clavicle can be investigated. In our case here to-day, 
the pectoralis minor was only partially removed, and it was not necessary 
to saw through the clavicle. Beginning at the pectoralis minor, all the 5 
connective tissue overlying the ribs and the Intercostal and the serratus 
magnus muscles was dissected down in one single layer, the lateral part 
of which was left in continuity with the tu nor and the pectoralis major. 
All along during this dissection, the vessels, veins as well as arteries, 
have been tied close to their origin from the axillary vein and artery. 
You saw these vessels and the cords of the brachial plexus clearly 
demonstrated, much more beautifully than is usually done in the dissect- 
ing room, fhe axillary vein was stripped of its sheath and lay there 
completely exposed in its entire course. One ol the small branches was 
torn off so close to the vessel that a lateral ligature of the axillary vein 
was made. 
We had then reached the line where the posterior and lateral walls 
of the axilla are joined and we have only to free the mass to be removed 
from its attachment to the subscapulans and the latissimus dorsi muscles. 
At this point ot the operation the surgeon must decide whether it is ex- 
pedient to save the subscapular nerves or not. 1 have cut them away in 
some cases, but to-day it was easy to save them and they were left. After 
putting the remaining tissues which held the now nearly loose mass upon 
the stretch, a lew cuts with the scissors ended the operation. 
If the operator has been careful to leave none of the connective 
tissue near the coracoid process, there will be no need of any further man- 
Ipulation or going over the ground aaain to search lor more suspicious 
tissue. Everything has been taken away in one piece. There has been 
no cutting into or laceration of the cancerous tissues. The wound was 
then closed, and by moving the skin we were enabled to close the entire 
wound without drainage. 
(When the first dressing was removed on the eighth day the entire 
wound was found healed; there was no elevation of temperature at any 
period of the convalesence). The operation was done with very little loss 
ol blood. 
The dressing which was applied here is the one that has given me satis- 
faction in over one hundred similar cases. It insures rest to the parts, the 
entire extremity, including the lingers, is included in the crinoline band- 
ages and a plaster of paris bandage over all insures immobilization. I con- 
sider rest of as much importance as asepsis in getting primary union. 
The essential points which should be understood and thoroughly 
practiced if local recurrance is to be avoided are: 
I. The pectoralis major muscle should be exercised in every case, 
or, at least, all except the clavicular portion. The minor may be cut 
through, or partially removed, if it is infected, or if it is in the way so as 
to prevent complete excision of all suspected tissue. 6 
11. By making use of this method all of the suspected tissues can 
be removed in one piece, together with the breast. 
The reasons which make it desirable to remove the whole mass in 
one piece are based upon th.i observations of local recurrence after opera- 
tions. Halsted. with whom I fully agree, think* that there is great danger 
“lest the wound become infected by the division of tissues invaded by the 
disease or of the lymphatic vessels containing cancer cells, and because 
shreds or pieces ot cancerous tissue might readily be overlooked in a 
piece-meal operation. 
The division of tissues which are cancerous, or pinching them with 
forceps, i* a thing that can be avoided by an operation such as you saw 
me do to-day, and this point is surely all-important. I have had the im- 
pression in operating for the removal of the cancerous uterus that local 
recurrence was due to the introduction of cancer juice, containing cells or 
small particles of cancer tissue into the open lymph spaces of the fresh 
wound. There are other points which we can not mention to-day that 
argue in favor of this theory ot inoculation. 
The after treatment of these cases is very simple. The patients are 
allowed full diet after the second day. I usually give a tonic, and in le- 
cent cases I favor a preparation calk d Zumo Auaua (pine-apple digestive 
wine), combined with tincture of iron. The former is a most efficient aid 7 
to dige-tion, a pleasant-tasting vehicle, and I have ordered it as a tonic 
wine where patients are convalescent with very beneficial results. 
There can be no doubt at the present day that cancer of the breast is 
a curable disease it operated on in time and by the complete method. I 
quote again from Halsted: “I can not emphasize too strongly the fact 
that internal melastases occur veiy early in cancer of the breast and this 
is an additional reason tor not losing a day in discussing the propriety of 
an operation.” 
This complete operation is not an easy operation; it can not be 
done at any time, at any place, or by any surgeon. It is a capital opera- 
tion, fraught with many difficulties, and should not be undertaken by a 
surgeon who has forgotten his anatomy It should not be done unle>s 
the surroundings are such that an aseptic wound can be made with 
certainty, and that the after care will be in the hands of competent trained 
nurses. 
Since we know that the result of a cancer case is found at the end of 
the broad and dreary road which leads to death, if allowed to run its 
course, I wish to enter my plea in favor of an early, complete operation. 
The proportion ot cases where the complete operation can not be done is 
about one-third, and even in these an operation will have a moral effect 
and palliate if it is not of much real benefit. Patients are often grateful 
for having a large, disfiguring and often offensive and putrid growth re- 
moved or changed into an aseptic inoffensive wound. 
Tiie patient left the hospital three weeks after the operation in ex- 
cellent condition, with a soft and pliable scar and no disability in the use 
ot her arm. 
2715 Locust Street. 
A. C. BERNAYS.