long enough after the three years' limit of time to state positively
that they are permanently cured. By studying the cases in sepa-
rate groups a better understanding can be reached as to the real
condition of the patients in each class, and at the same time the
grouping of the cases in this way gives general information as to
the condition of the sum total of cases and a more intelligent
knowledge of what can be expected in the future.
The iirst group comprises cases all of which have been cured
beyond the three years' limit of time and a few even twentj''-five
years, including a few with local recurrences in which secondary
operations were performed with no subsequent recurrences.
The second group comprises cases which have been cured beyond
the three years' limit of time but -which have died many years after
the operation from causes entirely independent of carcinoma.
The third group comprises cases all of which have been cured
beyond the three years' limit of time, but which have died many
years afterward from metastasis in the internal \dscera.
In the first group there were 39 cases reported in the list of 50
cases that carcinoma of the breast has been permanently cured.
A few of these cases have lived twenty-five years with no e\adence
of return, including, however, a few cases with local recurrences in
which a subsequent operation has been performed and the patients
immune from any further extension of the disease. All of these
39 cases lived from five to twenty-five years and all have been
watched from time to time, and nearly all of the 39 cases have
either been seen or heard from recently.
This group of cases affords much encouragement as to the
possibility of permanent cure. It proves beyond all peradventure
that a cure can be established in some cases, which fact can always
be a source of hope to those suffering from this much-dreaded
disease. It yet remains a myster}' as to what constitutes the
essential conditions to obtain this result. From the character of
the operation performed nearly a quarter of a century ago it fol-
lows that the operation itself was not the only factor involved.
The morphological condition of the tumor has much to do with
the prognosis, for in no other way can the permanent cure in these
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DENNIS: CANCER OF THE BREAST II9
cases be explained. The peculiar histological type of the carci-
noma seems to have an influence on the prognosis. There is
much to learn in regard to this phase of the subject and modern
scientific investigation will be certain to throw a flood of light
upon this dark subject. It is, however, established beyond
doubt that the more embryonic the cells are the more malignant
the cancer.
The second group comprises cases which have been cured beyond
the three years' limit of time, but wliich have died many years
after the operation from causes entirely independent of carcinoma.
In this group there were 4 cases out of the 50. These cases for
many years after the original operation were in perfect health.
They finally died from acute diseases, so that while they may be
said to have been cured no one can state, owing to the intervention
of death, whether in later years a return might not have occurred
if they had lived. All that can be said is that no return did occur
for many years, and that death resulted from special causes whoUy
disconnected with carcinoma.
The third group comprises cases all of which have been cured
beyond the three years' limit of time, but which have died many
years afterward from metastasis in the internal viscera.
There were 7 cases in this group in the 50 cases where the patients
lived for many years after the original operation, and who died
subsequently from metastasis in the internal orgians. The site
of the metastasis was not the same in all the cases. In 4 cases
the metastasis was in the lung and pleura, in 2 other cases it
was in the abdominal cavity, and in another case it was in the
pelvic glands and femur.
No better illustration of the uncertainty of permanent cures can
be adduced than by a reference to a single case in which for eight
years the patient was presumably cured.
In this case I removed a carcinoma and no return occurred in
the breast. The patient was over seventy years old and enjoyed
immunity from the disease for a period of eight years following
the operation, when she began to fail in general health and com-
plained of more or less intestinal disturbance. This condition
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I20 DENNIS: CANCER OF THE BREAST
increased for a year, more or less, when a small growth made its
appearance in the right iHac region. She died about six months
later or about eighteen months from the beginning of the appear-
ance of the growth. No autopsy was permitted; but it seemed cer-
tain that the growth was a metastasis from the breast, though it
occurred eight years after the original operation. This was a case
where the patient had lived many years after the standard time and
finally succumbed to the disease, when, according to our accepted
standard, she was supposed to be cured. Even if the time had been
extended to five years she was not cured with that standard.
This case, as well as others in the list, illustrates the important
clinical lesson that we must extend our period of time to feel in a
measure more certain of a permanent cure, and that five years is a
period where one can be nearly certain, from a study of these cases,
that a permanent cure is obtained. So few cases have a return
after five years immunity, that this period of time seems a standard
which would include nearly all cases of permanent cure.
In this list of 50 cases each had reached the three years' limit
of time and were all cured in accordance with the standard. In
reviewing, at the present time, these 50 cases reported to have
been cured, some interesting facts have been revealed. The result
of this thorough investigation has demonstrated the important
clinical fact : (i) That cancer of the breast is sometimes permanently
cured, or at least that twenty-five years have elapsed with no
evidence of a return; (2) that cases may go as long as eighteen
years and yet finally have a return in some other organ; (3) that
in the cases in which no return has been observed the operation
was performed almost without exception within six months from
the incipiency of the disease, thus showing the great importance of
early operation; (4) that the more radical the operation within
reasonable limits the better the prognosis; (5) that in some cases in
which the outlook was most unfavorable as manifested by extensive
ulceration, hemorrhage, widespread axillary involvement the end
results have been entirely satisfactory.
I. Cancer of the breast is sometimes permanently cured, or at
least twenty-five years have elapsed with no evidence of a return.
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DENNIS: CANCER OF THE BREAST 121
The 39 cases which were permanently cured, a very few of which
have been followed for a quarter of a century, clearly points
to the conclusion that surgeons have obtained a mastery over
this disease. This is especially true because cancer appears as a
rule late in life and immunity for many years entitles us to claim
a cure in these cases. I am convinced further that with certain
types of cancer the present radical operation will ensure a larger
number of recoveries than have been established in the past.
2. That cases may go as long as eighteen years and yet finally
have a return in some distant organ. A brief report of two cases
illustrates the clinical fact more forcibly than by any general
deduction.
The first patient suffered from a cancer of the breast upon whom
I operated eighteen years ago. The tumor was examined by
Professor Welch of Johns Hopkins University. After an expira-
tion of eighteen years, during which time she has been free from
the disease, she consulted me in reference to a small induration
in her other breast. The lump was small and situated near the
nipple. In the light of her previous history I felt justified in recom-
mending the inunediate removal of this breast to which proposition
she, as well as her husband, offered most serious objections. I
advised her to consult another surgeon who would give her an
independent opinion. This she did and returned with the verdict
of — ^not malignant. I then advised her to consult a third surgeon
who advised delay, but with the understanding that she was to
come to see him again in a month as he might change his opinion.
She returned to me, however, and finally decided to have the opera-
tion, which I accordingly did, and Professor Ewing made a micro-
scopic examination, and pronounced it to be a carcinoma. Two
years have now elapsed and she is thus far free from any evidences
of a return. It is, however, too soon to predict the outcome in
the second operation. This case illustrates the fact that even
eighteen years may elapse with no return of the disease in the
breast, but that after that long period of time a new outbreak or
a new carcinoma may appear in the remaining breast. It shows,
moreover, that cases reported cured may in years to come develop
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122 DENNIS: CANCER OF THE BREAST
a new carcinoma not in the site or region of the first operation, but
in the remaining breast.
The second patient was operated upon by me for a sarcoma of
the breast, fourteen years ago, and during this time she has been
free from all indications of this disease. One year ago she con-
sulted me for some trouble in her remaining breast. While I was
not positive as to the precise nature of this new trouble, I advised
an inunediate removal of the breast, taking into consideration her
previous clinical history. Professor Ewing states that this second
breast is a carcmoma and not a sarcoma, as was the case in the first
breast. We are here confronted with a peculiar history. A sar-
coma in one breast, and, after fourteen years of supposed permanent
cure, a malignant disease of another type altogether develops in
the second breast. The question naturally arises in this case: Was
not the sarcoma cured and was not the carcinoma in the other
breast a purely incidental outbreak of a new disease and wholly
independent of the original disease from which she suflFered four-
teen years ago and from which she appeared to be cured? The
more I study these cases the more I am convinced that our knowl-
edge is still incomplete and that much is to be learned as to the
behavior of malignant disease in the individual case.
3. That in the cases in which no return has been observed the
operation was performed almost without exception within six
months from the incipiency of the disease thus showing the great
importance of early operation. This point seems to me of great
importance in relation to the prognosis. I have examined my
cases and find that in nearly all of the permanent cures the opera-
tion was performed within six months of the appearance of the
disease. Too much importance cannot be placed upon this fact,
because it is without question that the earlier the operation the
better the prospects of cure. This is true because glandular infec-
tion is not so likely to occur and the patient is in better physical
health from absence of worry and pain. This fact should impress
the family physician with the responsibility of referring his patient
early to a surgeon who then must assume the responsibility of this
momentous question. No growth, however small, should be dis-
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DENNIS: CANCER OF THE BREAST 1 23
regarded, especially if the patient is approaching the menopause.
It is with a view to prophylaxis that the mortality of death from
cancer of the breast is to be still further reduced.
In regard to the fourth clinical fact, the more radical the operation
within reasonable limits the better the prognosis.
It seems imnecessary and a loss of time to discuss this point,
since it is universally admitted that the more radical the operation
the less likely it is that the disease will return. The diflSculty
seems to be as to what constitutes a radical operation. All sur-
geons agree that all skin over the infected area should be sacrificed,
the breast with Sir Astley Cooper's ligaments should be entirely
removed, together with the pectoral fascia and muscles, the axillary
glands dissected out, and also the perimammary and retromammary
fat and the paramammary areolar tissue, as the minimum operation.
If the cancer involves the ribs and perforates the thoracic wall,
and has already infected the mediastinal glands, no operation,
however radical, would be attended with any success. The same
rule may also apply to that form of cancer termed encuirass or
enplaques, or acute miliary carcinosis.
I am firmly convinced that any radical operation more than has
been described will be of no avail. The element of time should
be seriously considered, since the performance of any operation
which requires the patient to be under an anesthetic for four or
five hours is attended with a risk which should, if possible, be
obviated. These prolonged operations are sometimes followed by
ether pneumonia, acute sepsis, profound shock, suppression of
urine, and many other like conditions which jeopardize the life of
the patient. In other words, we must not lose sight of some of the
general principles connected with surgery at the expense of the
elaboration of an operation, the performance of which eliminates
some of the best precepts and practice of our art.
5. That in some cases in which the outlook was most unfavor-
able, as manifested by extensive ulceration, hemorrhage, widespread
axillary involvement, the end results have been entirely satis-
factory. No better proof of this statement can be made than by a
brief reference to 2 cases occurring in the list of 50 cases. It
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124 DENNIS: CANCER OF THE BREAST
seems pertinent to call attention to these two cases because they
demonstrate the possibility of a cure when everything looks hope-
less. I admit we cannot place any reliance upon a cure when
cases present such a chain of unfavorable symptoms. It only
shows that surgeons should not withhold an operation from the
patient even when the outlook is most discouraging. If there is a
possible chance in any case the patient should have the benefit
of the doubt. It is always best, however, to explain to the friends
the true situation and then they will not be disappointed if the
operation is attended with a quickly fatal result.
The first patient had a foul, ulcerating hemorrhagic and fungous
breast with axillary enlargement. I advised the operation, not
with the expectation of curing the disease, but purely from a
humanitarian point of view. I felt sure that the hemorrhages
could be in a large measure controlled, the offensive smell to a
greater or less extent be removed, the constant pain at least for a
while relieved, and with a view to euthanasia the patient might be
made more comfortable while she lived. To my surprise, after
eight years, she has been free from disease, and to all intents and
purposes is at the present time in perfect health. The opera-
tion was radical and I am at a loss to explain the cure under these
conditions.
The second patient was the victim of a fungous, hemorrhagic,
foul-smelling carcinoma of the breast. I hesitated to operate at
all but did so at the request of the husband, with a full understand-
ing that the operation was one to palliate the distressing symptoms
and with no expectation of cure. This operation was performed
four years ago, and today, to my astonishment, she is perfectly
well and has no evidences of any return of the disease. Both of
these tumors were examined by microscopists of world-wide repu-
tation, who pronounced them carcinoma. I merely mention these
2 cases in the list of 50 to illustrate the fact that sometimes
the most hopeless cases recover, and they appear to me to urge
the surgeon to operate in the most desperate cases with the most
forlorn prognosis, provided the tumor is not adherent to the chest
wall. I can ofiFer no explanation as to the behavior of these two
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DENNIS: CANCER OF THE BREAST 1 25
tumors, but they seem to me worthy of record as evidence that oui
knowledge is still incomplete in regard to the course of certain
types of cancer of the breast.
Finally, from a review and study of these 50 cases it follows
that surgery has made distinct advances in the cure of this most
dreaded disease. It also follows that much is to be learned in
regard to the accomplishment of a more uniform percentage of
recoveries. It is also obvious that surgery must direct its attention
to a study of the factors which influence the results of operative
treatment. It is likewise evident that a more unanimity of opinion
must be arrived at by surgical pathologists whose work in the
histological formation of cancer is yet far from satisfactory, as
one pathologist denominates a certain tumor cancerous while
another calls it by some other name. This leads to confusion and
destroys the value of the results of operative treatment. The ques-
tion of metastasis, too, demands more careful research, as it is yet
far from clear as to where the metastasis is likely to occur in the
individual case. The tendency of certain benign breast tumors is
not yet understood. The period of time as to what constitutes a
permanent cure following an operation is not agreed upon by all
surgeons. The radical character of the operation is admitted by
all as the one essential factor in the operative treatment. This
widespread discussion before this Association today should have
an influence for good on behalf of those suffering from cancer of
the breast, and in years to come operative treatment in this depart-
ment of surgery should give satisfactory and brilliant results.
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END RESULTS FOLLOWING OPERATIONS FOR
CARCINOMA OF THE BREAST.
By willy MEYER, M.D.,
NEW YORK.
It had been my endeavor to bring a collective report of the final
results of operations for carcinoma of the breast, done by the
various operators at the German Hospital, of New York City. But
this proved impossible, for, with the ever-shifting population of
this cosmopolitan centre, attempts at tracing cases to end results
usually bring but unsatisfactory returns, and often are connected
with unsurmoimtable difficulties. It took me more than six
months of hard work in 1904 to prepare my statistics. I am,
therefore, today in a position to present only my personal statistics
of cases operated upon by the method first described by me in 1894
{New York Medical Record^ December 15, 1894), and again more
fully in 1905 ("Carcinoma of the Breast; Ten Years' Experience
with my Method of Radical Operation," Journal of the American
Medical Associalian, July 29, 1905). In order to be able to pass
an opinion on final results, obtained with one and the same opera-
tive procedure, all cases of carcinoma of the breast, operated on
prior to 1894, were not included in the following statistics.
From September, 1894, to April i, 1907, I have performed the
radical operation 86 times in 84 patients, 2 having developed
the same disease in the opposite breast not long after the first
operation. Of these, 83 were females; i male. The youngest
case was twenty-eight years of age, the eldest seventy-two; the
man was forty-four years old.
Classified into decades, the ages of my patients range as follows:
One was between twenty and thirty years of age; 14 were be-
tween thirty and forty; 38 were between forty and fifty; 18 were
between fifty and sixty; 11 were between sixty and seventy; 2
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MEYER: CARCINOMA OF THE BREAST 1 27
were between seventy and eighty: total, 84, showing the greatest
number of cases to have occurred in the fifth decade.
Fifty- three cases were private patients; 31 were operated upon
in the wards of the German and Post-Graduate Hospitals. Of the
former I have careful records as to their subsequent history; of
the latter, 4 could not be traced. One of these, operated upon in
June, 1903, at the age of forty-three, was alive and well in January,
1905, but since then has been lost track of.
Again, I am greatly indebted to Dr. Martin Rehling, of New
York, who rendered such invaluable assistance in compiling my
statistics two years ago, for his efforts in personally ascertaining
the present condition of the surviving ward patients.
Deducting the 4 patients who could not be traced, there remain
80 for consideration here.
Sixteen of these were operated upon from ten to twelve and one-
half years ago, i. e., between September, 1894, and April, 1897,
and of this number i died of diabetic coma forty-eight hours after
operation; 8 died of recurrence or metastasis from one to three
years after operation; 2 lived nearly four years, when they died
of internal metastasis; i was well for eight years, when she de-
veloped regional recurrence; i was well and free from recurrence
six and three-quarter years, when she died of endocarditis; hence
3 (18.7 per cent, of this series) are alive and well today, from
eleven to twelve and one-half years after operation, namely, twelve
and one-half, twelve and one-twelfth, and eleven and one-twelfth
years, respectively, a total of 16.
Twenty-seven patients were operated upon from five to ten
years ago, i. e., between April, 1897, and April, 1902. Of these
17 died of recurrence or metastasis from one to three years after
operation; 2 died of recurrence nearly five years after operation;
I (seventy-two years old) lived in perfect health for six years after
operation, when she developed a rapidly-growing cancer of the
stomach, in the absence of any local or regional recurrence; i, a
pronounced diabetic at the time of the operation, was well for six
years, when she succumbed to diabetes without having developed
any signs of a return of the old disease; 6 (22.2 per cent.) are alive
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J 28 MEYER: CARCINOMA OF THE BREAST
and well today, from five and three-quarters to nine and one-half
years after operation, viz., nine and one-half, eight, seven and three-
quarters, seven, six and one-half, and five and three-quarter years,
respectively, a total of 21.
One of these latter was operated upon by me for carcinoma of
the right breast in March, 1899. In December, 1900, she re-
turned to me with a carcinoma of the left breast, which I then
also extirpated. She has been well and free from recurrence
since, six and one-quarter years after the second operation.
From the above it appears that of 43 patients operated upon
between September, 1894, and April, 1902, 17 (equal to 39.5 per
cent.) have remained free from recurrence from three to twelve
and one-half years after operation; or 13 (equal to 30 per cent.) from
five to twelve and one-half years after operation; 9 (equal to 20.9 per
cent.) bemg alive and well today.
Twenty patients were operated upon from three to five years
ago, i. e., between April, 1902, and April, 1904. Of these 8 died
of recurrence or internal metastasis from one to three years after
operation; i died three and one-quarter years after the same; i,
twenty-eight years of age, the youngest of all my patients, had a
regional recurrence two and one-half years after operation, for
which she was operated upon and remains in statu quo under
continued x-ray treatment; 10 (equal to 50 per cent) are alive and
well today, from three to four and three-quarter years after opera-
tion, i. e., four and three-quarter years (i patient), four and one-half
years (3 patients), four years (i patient), three and three-quarter
years (i patient), three and one-quarter years (3 patients), and three
years (i patient), respectively, a total of 20.
This latter series includes the only male patient I have had,
who is well now, three and three-quarters years after operation.
Seventeen patients were operated upon during the last three
years, i. e., from April, 1904, to April, 1907; i, a ward patient,
died two weeks after operation of secondary infection, after the
principal part of the woimd had healed up by primary union, all
grafts having taken, the first dressing having been changed on the
sixth day as usual; 5 died of regional recurrence from one to two
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MEYER: CARCINOMA OF THE BREAST 1 29
and three-quarter years after the ablation of the breast; i, sixty-
seven years old, has developed a local recurrence seventeen months