Removal Of The Cancerous Breast

The origin of cancer is now believed to be local and not general and the more complete its removal the greater is the likelihood of cure. Therefore every effort is made to excise every possible infected tissue. This has led to the performance of very extensive operations.

The incision is made so large as to include nearly or quite all of the skin covering the glandular tissue; this is because of the intimate connection of the two, as already pointed out. It is carried out to the arm; this is to facilitate clearing out the axilla and all its contents. The incision is kept close to the skin; this is to avoid any glandular structure which may possibly be beneath. The pectoral fascia covering the pectoral muscle is always removed.

Often both the pectoralis major and minor muscles are removed. In excising them the slight interspace between the clavicular and sternal fibres of the pectoralis major muscle is entered and the muscle detached from the anterior extremities of the ribs and sternum. In so doing the anterior intercostal arteries, particularly those of the second, third, and fourth spaces, are liable to bleed freely. As the pectoralis major is detached and turned outward, the acromial thoracic artery is seen at the inner edge of the pectoralis minor muscle with its pectoral branch running down the surface of the chest. This may be ligated, the finger slipped beneath the pectoralis minor, and this muscle cut loose from the coracoid process above and the third, fourth, and fifth ribs below. At this stage some operators clear the subclavian and axillary vessels of all loose tissues and lymph-nodes.

The vessels are followed out on the arm. When the insertion of the pectoralis major is reached it is detached and the whole mass turned outward and pared loose along the anterior edge of the scapula. Thus it is removed in one piece. The part of the chest-wall which has been cleared off embraces from the middle or edge of the sternum to the anterior edge of the scapula and from near the lower edge of the chest below to the clavicle above. The vessels have been cleared off from the insertion of the axillary folds on the arm to underneath the clavicle. Many operators make an additional incision above the clavicle and clear out the supraclavicular fossa even if no enlarged glands can there be detected. Sometimes the long thoracic artery and thoracicalis longus (long external thoracic) nerve may be wounded, but they need not be. (See note, page 191).

Two nerves will be seen crossing the axilla from the chest to the arm. They are the lateral branches of the second and third intercostal nerves. The second is called the intercostobrachialis (humeral) nerve. If they can conveniently be spared it is to be done, otherwise they are divided. In clearing the axillary vessels, small veins and even arteries may be divided close to the main trunks. These may be expected to bleed freely but are usually readily secured. Care should be taken not to wound unnecessarily the subscapular artery and particularly the vein as they wind around the anterior edge of the scapula 2 to 3 cm. below its neck. Some operators prefer to detach the breast from without in instead of from within out as described.