In these operations, besides the same preparations as for all bloody oper ations, the following instruments are used: a scalpel of medium size, scissors, toothed forceps, Muzeux's forceps, sharp double forceps, a large number of sliding catch forceps, threaded suture needles with needle holder, sewing material; compresses and bandages must be at hand. All these operations should now be done by the antiseptic method, and every thing necessary for this should be prepared.
The patient to be operated upon is best placed upon a table, with the upper part of the body somewhat elevated. If the skin over the tumor is movable and healthy, and if the size of the tumor is not larger than that of a moderate sized apple, the incision through the skin should corres pond to the longest diameter of the tumor, and should be made only after the tumor has been grasped by the left hand and fixed. After the incis ion, the tumor will push forward, and a few superficial lateral incisions will be sufficient to almost entirely remove it; the tumor is then seized with the left hand or by an assistant, or grasped with Muzeux's forceps, is drawn forwards, and cut away with the knife or scissors. This is easily, done with encapsulated tumors, but is impracticable with carcinoma: here the skin must be dissected away, the tumor drawn forward, and sound tissue removed from the gland substance for about one inch outside of the tumor and carcinomatous induration.
If the skin is adherent to the tumor, or is very thin over it, or if ulcer ation has already taken place, a part of the adherent or ulcerated skin is removed by an oval incision. The long direction of this oval incision is best made from above and to the outer side, downwards to the lower and inner side, as in this way the incision may be easily carried into the axilla if extirpation of the axillary glands is shown to be necessary.
Total extirpation of the breast is done in the same way, except that the oval incision runs around the breast, and to get a better view of the field of operation, the arm on the affected side is held up. More or less skin is removed according to the size of the tumor, the extent of the adherence with the skin, or the ulceration; the gland is then raised and separated from the pectoralis major muscle, cutting from above downwards, an easy operation. If the tumor is adherent to this muscle, much of it must also be removed, whereby the ribs will often be exposed. If portions of
the gland remain (especially below and outwardly, and above), they must be removed with the scissors. When there is an abundance of adipose tissue, whatever feels hard or nodular is cut away from it, as such places are always to be looked upon as beginning carcinomatous infiltrations; feeling is much better here than seeing.
These operations must be done quickly, because the blood sometimes streams from a great number of arteries. Immediately after the removal of the diseased parts, the arteries should be seized with slide forceps, and after removal of the gland, must be ligated or compressed by means of a suture. When the hemorrhage is controlled, the wound must be very carefully examined for any trace of diseased or suspicious tissue, and this immediately be removed by the scissors if found.
If the axillary glands are swollen or indurated these glands must now be extirpated. For this purpose the incision is carried from the existing wound as high up into the axilla as is necessary, in order to get at the swollen glands; in doing this the border of the pectoralis major muscle is laid bare, thus bringing us to the fascia, which is to be cut through. The finger can now be forced in and all the glands and fat be shelled out from the axilla and under the pectoral muscle. In doing this the glandular vessels are isolated with closed forceps or closed scissors, two'buemostatic forceps or slide forceps being placed on each vessel, and the vessel cut between them. Then the central (proximal) end is ligated, and the for ceps removed. The long thoracic artery usually has to be tied. If the glands are all adherent to one another and to all the vessels and nerves, the operation is very difficult; it is very easy to tear the axillary vein and artery, and care, circumspection and presence of mind are necessary to remove all the diseased portions without wounding these vessels. I may advise that the operation be not undertaken without sufficient assistance, and not unless such operations have been previously witnessed. If the operator should be so unfortunate as to tear the axillary vein, it is best to place a double ligature on it immediately, as the entrance of air, with fatal consequences, has been observed.