A Manual of the Operations of Surgery, page 209 by Joseph Bell
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isease for which the operation is performed, and the extent to which the skin is involved; in every case the whole nipple should be removed. The incisions should, if possible, be parallel with the fibres of the pectoralis major, and extend across the full diameter of the breast. During the operation the arm should be extended so as to stretch both skin and muscle. The lower flap should be first raised and dissected downwards, with care that the cuts are made in the subcutaneous fat, and wide of the disease; the upper flap is then thrown open, and the edge of the gland raised, so that the fibres of the pectoralis are exposed below it. These should be cleanly dissected, so as to insure removal of the whole gland.
Any bleeding during the operation can easily be checked by the fingers of an assistant, and if the arteries entering the gland from the axilla be divided last, they can be at once secured. If there are many bleeding points, the application of cold for a few hours before the wound is finally closed is a wise precaution.
The requisite stitches may be inserted while the patient is under chloroform, but not tightened. The arm should then be brought down to the side, and a folded towel laid over the wound after it is finally closed. Great benefit results from the free use of drainage-tubes in most cases; for this purpose a dependent opening in the lower flap is often made.
Surgeons now operate even when the axillary glands are diseased, and by a very free dissection and removal, even in hopeless-looking cases, life may be prolonged. To insure the removal of the lymphatic vessels as well as the glands, it is best not to separate the breast at its axillary margin, but keep it attached by the tail of lymphatics surrounded by fat, which will lead up to the glands. Section of the great pectoral muscle will aid the dissection.
When the tumour is very large, and the skin has been much stretched and undermined, more complicated incisions may be necessary; these must be governed a good deal b