after operation (tumor of the right rib beneath the grafted area) ;
I, forty years old, an advanced case, showed a recurrent nodyle
surrounding one of the subscapular nerves, eleven months after
the operation — ^immediate extirpation, regional recurrence (mul-
tiple) three months later; 9 are alive and well today: total, 17.
Of these latter, i was operated upon two and three-quarter years
ago; 7 between April, 1905, and April, 1906; the remaining i
within the last year. Thus, of the entire 80 patients, 28 (equal to
35 per cent.) are alive and well today, 9 of these having been
operated upon less than three years ago; 4 (equal to 5 per cent.)
lived from six to eight years after operation; i of these died of a
regional recurrence, i of metastasis, 2 of diseases not in any way
connected with the original trouble; 28 (equal to 44.4 per cent.)
lived from three to twelve and one-half years after operation; 5
(equal to 6.25 per cent.) lived from three to five years after opera-
tion; 3 others (equal to 3.75 per cent.), though living, have de-
veloped either local, regional, or metastatic recurrent growths;
40 (equal to 50 per cent.) have died within three years after opera-
tion; 2 of these died shortly after the operation — i on the second
day, of diabetic coma; the other, after two weeks, of secondary
infection; 16 within twelve months (equal to 20 per cent.), and 8
within twelve to eighteen months (equal to 10 per cent.) ; or 24
(equal to 30 per cent.) within one and one-half years after operation.
Reviewing my statistics, I will here refer to a few points in addi-
tion to those discussed in my previous paper:
In 8 of the 40 cases that have died within three years after the
operation there was neither local. nor regional recurrence, death
being due to internal metastasis (spinal column, stomach and in-
testines, mediastinum and brain). It is plausible to assume, I
think, that in many of these cases the infection of the respective
organs had existed prior to the operation.
With regard to the desirability of cleaning out the supraclavicular
space at the time of operation, even in the absence of clinical evi-
dence of the presence of cancerous glands in this region, I can but
AmSurs 9
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I30 ICEVES: CARCINOMA OF THE BREAST
say that my own experience does not speak in favor of such a pro-
cedure. In none of my 13 patients who remained well from five to
twelve and one-half years were the supraclavicular glands removed.
The question as to whether the subscapular nen-es should
be presen-ed at all hazards, as strongly advocated by Kuster
twenty years ago/ still remains sub judice. Personally, I alwa\-5
try to presen-e them. I would say, however, that in three cases
I have seen the first regional recurrent nodule embracing, as it
were, the second subscapular nerve which ran through its centre.
In all three of these cases the disease spread in spite of most
thorough excision of this nodule. Of course, to sacrifice one or
more of the subscapular nerves in all cases would entail great
hardship for the patient, in view of the resulting disability as regards
the proper use of the arm.
In three cases the axillary vein was removed, together with the
mass, from a point just below the entrance of the cephalic to a
place corresponding to about the begiiming of the bicipital sulcus.
This procedure wonderfully facilitated the otherwise particularly
diflScult preparation. No disturbing sequelae were observed. Of
course, great care was taken not to interfere with the cephalic vein
or with the proximal part of the axillary beyond the entrance of
the former.
Edema of the arm has been a rare observation in my cases. I
have noted it in a transitory shape in about 10 per cent. The
cicatrix has oftener been the causative factor than glands,
compressing the subclavian or axillary vein. In only one of my
patients did it persist to some extent. This one was operated
upon four and one-half years ago.
The postoperative neuralgia, or neuritis, of the brachial plexus
has proved to be temporary in every instance. Of the prevention
of these sequeke, by means of Murphy's muscle plastic, I am not
in a position to speak, owing to lack of personal experience so far.
I think it worthy of special mention that every one of my
patients has full use of the arm.
That the extent of involvement is an important factor regarding
* Zentralbl. f. Chinirgie, March 12, 1887.
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MEYER: CARCINOMA OF THE BREAST I31
the prognosis of the case, stands to reason. If the disease has
reached an advanced stage, especially when there is involvement
of the supraclavicular lymphatic glands, there is little hope for a
longer freedom from recurrence. Every one of such patients,
operated upon by me, died soon after. Eight of these cases are
valuable for conclusions. In two of these, glands were primarily
removed with the other tumor; in five, secondarily, in the absence
of either local or regional recurrence. None of these lived longer
than nine months. The eighth patient, in whom another surgeon
had done a rather conservative operation two and one-half years
before she came to me with local recurrence, and upon whom I
then performed my radical operation plus cleaning out of the
supraclavicular space, lived twenty-one months.*
In spite of the sad prognosis of these cases, I nevertheless think
the removal of the glands, if enlarged, should be undertaken in
every instance, for I consider it the surgeon's duty to extirpate
whatever can be reached with the knife, so long as metastases do
not forbid such a procedure. Sometimes life may be prolonged
more than seems possible at first sight, as the case just cited well
illustrates. This patient lived for one and three-quarter years in
the full enjoyment of life; then a tumor in the mediastinum caused
death — local and regional recurrence as well having taken place.
It will be interesting to scan the cases with regard to the seat of
the primary breast tumor. If the growth is found in the upper two
quadrants of the breast, particularly if it involves the skin and the
subcutaneous tissue over this region, infection of the supraclavic-
ular glands may be expected (Poirier, Cun^o, and Delamere, The
Lymphatics y p. 215). This was found true in the great majority
of my cases.
Regarding a possible difference in end results between scirrhus
or adenocarcinoma of the breast, I can offer no definite conclusions,
as the reports with reference to the pathological variety of the
growths are not complete in all my cases. However, judging
* In this case, as became evident from the symptoms that appeared on the
third day after operation, the thoracic duct was injured beneath the clavicle. It
clolsed spontaneously in course of healing.
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132 MEYER: CARCINOMA OF THE BREAST
from the cases that can be utilized for this question, the prognosis of
adenocarcinoma seems less favorable than that of the scirrhous type.
I consider the jc-rays valuable in the immediate after-treatment.
Every patient is urged to submit to a six to eight weeks' course as
soon as healing has been accomplished. I have one case which,
at the time of operation, gave a bad prognosis. Here the faith-
ful intermittent use of the :v-rays, during a number of years, had a
most gratifying result. No reourence for four years.
The duration of the disease prior to operation naturally plays an
important role with regard to end results. Let me say here that
in no case did I refuse the radical operation, except metastasis for-
bade it. Of course, the earlier it is done the better for the patient.
Still, I believe the degree of malignancy of the disease and its ten-
dency to rapid proliferation often to be the more important factors
in determining the patient's fate. I have a number of cases, espe-
cially among my yoimger patients, in whom I operated at what I
consider an early stage, and yet they developed internal metastases
(brain, spinal column, etc.) with astonishing rapidity, in spite of
the same complete operation. But, knowing the treacherous,
perhaps even directly infectious, nature of malignant disease, we
should, even in the face of such sad experience, not allow our-
selves to encroach on the magnitude of the operation. Since a
refined diagnosis as to the virulency of the disease in the given case
is impossible, radical work is a necessity in every instance, and
best, it seems to me, such radical work as does not spare skin,*
divides the lymphatics first and then keeps outside of the infected
area as much as possible, the cuts being made within healthy tissues
as far as this can be done. In other words, the operation should
consist in removing both pectoral muscles with the diseased breast,
glands, and surrounding fat in one mass.
Even doubtful cases will fare better by such a procedure than
by an operation of less magnitude or undue temporizing.
* Oflen have I seen local recurrence in the skin closely bordering the grafted
area. It is my opinion that sometimes we are induced to save skin in order to
be enabled to close the defect without. grafting. This is the reason why I would
not make up my mind, so far, to adopt Jackson's excellent skinplasty (Jour.
Amer. Med. Assoc., March, 1906) .
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END RESULTS FOLLOWING OPERATIONS FOR
CARCINOMA OF THE BREAST.
By lewis STEPHEN PILCHER, M.D.,
NEW YORK.
In the present communication I wish to emphasize more especially
results obtained in cases in which, at the time of operation upon the
breast, the lymph nodes above the clavicle were already infected,
and the supraclavicular spaces were cleared out in addition to the
t}'pical operation upon the thorax and axilla. I do this especially
because of the frequency with which I have met expressions of
skepticism from men of large clinical experience, as to the value of
extending operative attack above the clavicle; their skepticism
being based upon their apprehension of the great probability that
when the supraclavicular nodes were appreciably affected, the
infection had already extended into the mediastinum, so that even
after the removal of the supraclavicular masses the operation
would necessarily still be incomplete.
No one for a moment would dispute the increase of gravity of
prognosis in a case of breast carcinoma in which the transmitted
infection had reached the supraclavicular lymph nodes, but that
this should always render the prognosis practically hopeless is not
in accordance with clinical experience. When, therefore, my col-
leagues say to me that they never invade the supraclavicular region
in their work for breast carcinoma, I am influenced to inquire
whether they are not thereby permitting a certain proportion of
cases to proceed to a continuance of carcinomatous development
which a further extension of their work of eradication might have
prevented.
In a study of my results in operations for breast carcinoma.
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134 pilcher: carcinoma of the breast
published in 1900, 1 found that in 10 of the cases in which enlarged
supraclavicular nodes were discovered and removed, 3 remained
free from recurrence. These I have been able to follow to
the present time, May, 1907; i case has since died from cardiac
failure at the age of seventy-five, more than seven years after
operation, without recurrence of cancer; the 2 others are still
living, free from recurrence, nine and seven years, respectively,
having elapsed.
During the six years, 1901 to 1906, inclusive, 34 additional cases
of breast carcinoma have come to operation at my hands; 5 of these
were manifestly and unavoidably incomplete operations, the benefit
was but partial and temporary and the steady advance of the
disease was uninterrupted; i of these died on the table.
In II instances, application for relief had so promptly followed
the discovery of the presence of the disease that in my judgment
it was proper to limit the operative attack to the clearing out
of the axilla and the removal of the pectoral muscles with the
affected breast and its overlying skin. The results in these cases
have been so extraordinarily good that I almost hesitate to record
them, for they entirely reverse all my previous experience and
preconceived opinion; 9 out of the 11 have thus far remained free
from recurrence, periods of four years, three and one-half years,
two years, eighteen months, in 5 instances, and six months,
respectively, having elapsed. In the remaining 2 it is reported
that there is now a lump in the other breast, the nature of which
has not been determined. My reference to these cases is simply
en passant.
It is the remaining group of cases, 18 in number, in which the
evident extension of the disease at the time they first presented
themselves was great enough to awaken apprehension of possible
infection of the lymph nodes above the clavicle that I wish to dwell
upon more particularly. . In these cases, in 4 instances glandular
masses in the neck were distinctly palpable before any section of
the overlying coverings was made. Of the 14 cases in which the
examining finger could not appreciate the presence of diseased
nodes in the neck, the section revealed, nevertheless, that in 11,
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pilcher: carcinoma of the breast 135
infected nodes were present, and that in only 3 of the number,
appreciable disease was not recognizable upon section.
As to the end results in these cases:
Of the 3 cases in which the neck was opened and the supra-
clavicular region cleaned out without the discovery of any notice-
ably infected glands in the neck, all have remained well to date, at
periods of five years, one and one-half years, and one year, respec-
tively.
Of the 4 cases in which the supraclavicular glands were pal-
pable ante operationem, i case died three months after operation
without further external manifestation of disease, but by pro-
gressive asthenia doubtless due to internal carcinosis, the opera-
tion evidently having been an incomplete one.
The second case one year later had developed multiple recurrent
nodules in the thoracic region; these were kept imder control by
X'Tdiy treatment for two years. At the end of four years she had
developed a growth in the remaining breast, and was subjected to
a complete operation for its removal; later, she developed intra-
thoracic metastases from which she died five years after the pri-
mary operation.
In the third case, a suspicious nodule developed upon the
thorax within the first year after operation; this disappeared under
the influence of the :r-ray, and the patient thereafter remained in
good health for two years, at the end of which time she died, as
reported, from pneumonia. The case is not altogether free from
the suspicion of a carcinomatous element in the pulmonary con-
dition.
The fourth case remains well without suggestion of recurrence,
two years after operation.
The II remaining cases in which the neck was opened and
infected glands found to be present although they were not pal-
pable until after the neck was opened, likewise, though in a less
degree than those first mentioned, belong to the group of neglected
cases which experience has shown may be expected to differ greatly
in the operative results obtained from the early attended cases.
Among these 11 women the length of time that had been
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136 PILCHER: CARCINOlfA OF THE BREAST
allowed to elapse after the presence of the growth was known before
accepting operation for removal, was two years in i case, between
one and two years in 4 cases, six months in 4 cases, and one month
in 2 cases only. It has been possible to follow the later history
of all but I. One died from myocarditis seven weeks after the
operation, leaving 9 cases to be accounted for; of these, 3 developed
speedily both regional and distant metastases, the removal plainly
having been incomplete, and they all died within the year; a fourth
was reoperated at the end of a year for a recurrent nodule in the
lateral thoracic region, and no further external metastases became
manifest in this case, but carcinoma of the liver developed, result-
ing in death three years after the primary operation; a fifth case
remained well for four years, but during the fifth year — the present
year — ^there have developed both supraclavicular and thoracic
recurrences; she is still living. Four cases still remain free from
recurrence at periods of three years, three years, two years, and
one year, respectively, since operation.
In two previous papers, in 1902 and 1905, respectively, I have
dwelt upon the importance of opening the base of the neck as a part
of the routine operative procedures in cases of breast carcinoma.
Even the limited experience contained in the comparatively sjnall
number of cases included in my own statistics is sufiicient to indi-
cate that in a considerable proportion of cases the supraclavicular
nodes become early infected, so that operations for the removal
of carcinoma originating in the breast must often be incomplete if
the base of the neck be not cleared of its nodes, as well as the
axilla. The point of suspicion — the key to the whole situation,
in many cases — is the triangle at the junction of the subclavian
and internal jugular veins, where rest the node or nodes which are
the sentinels that guard the entrance to the mediastinal lymphatic
paths and to which run not only the lymphatics which pass up under
the clavicle from the axilla, but also an inconstant but not infre-
quent set of ducts which run up on the front of the thorax from the
mammary region to the base of the neck, down into which they dip
after rimning over the inner end of the clavicle.
When the neck is opened this jugulosubclavian triangle is
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pilcher: carcinoma of the breast 137
first to be exposed, explored, and cleaned, and from it, outward,
the lymphatic-bearing tissue can be best systematically dissected
out en bloc.
So dense is the deep fascia at the base of the neck that, together
with the overiying adipose tissue and skin, it forms a covering
which renders infected nodes difficult to detect by palpation until
they have attained quite a size. When such nodes hav^e become
distinctly palpable or visible the presumption is that the infec-
tion is of long standing and of considerable extent. They are of
ominous portent and fully justify the gravest prognosis. That even
then the infection may still be confined to the accessible supra-
clavicular group, so that their extirpation may ensure a complete
removal of all carcinoma-bearing tissue, has been demonstrated in
enough instances to encourage surgical attempts in all but the
plainly hopeless cases. Of more importance, however, is the prac-
tical recognition of the probability of the presence of infection of
the supraclavicular nodes in every case of breast carcinoma of
much duration or extent, and the incorporation into the general
plan of operative attack, in all such cases, of an incision into the
base of the neck and a systematic removal of all possibly infected
tissue, even though there may be no distinct evidence to sight or
touch before such incision, of the presence of such infection.
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END RESULTS IN OPERATION FOR CARCINOMA
OF THE BREAST.
By albert VANDER VEER, M.D..
ALBANY, NEW YORK.
When I began the preparation of my paper, of which I present
only an abstract today, it was my intention to include the histories
of cases occurring in my practice during the past twenty-five years,
but at this date I find it quite difficult to get so complete a list of
end results as I could wish; therefore, it has seemed better for
me to continue this line of investigation for a longer period and
to give only a few of the conclusions regarding my impressions of
the operation for carcinoma of the breast, as I have observed it
since moving into our new hospital, from May i, 1899, to May
I, 1906.
In this period there were 103 cases from which to draw conclu-
sions regarding end results.
As to the relative proportion, in the different decades, they
presented as follows:
Cases.
From twenty to thirty years of age i
From thirty to forty years of age 15
From forty to fifty years of age 35
From fifty to sixty years of age 32
From sixty to seventy years of age 16
From seventy to eighty years of age 4
Total 103
Family history negative in 53
Family history tuberculous 25
Family history carcinomatous 18
Family history carcinomatous and tuberculous ... 5
Family history not stated 2
Total 103
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VANDER veer: CARCINOBIA OF THE BREAST I39
Cases.
Left side 60
Right side 41
Both sides 2
Total 103
Deaths 17
Known to be living 70
Not heard from 16
Total 103
Later I hope to give statistics of all of my work in this field of
surgery, and in such a manner that more careful and intelligent
conclusions, regarding end results, may be reached. Time will
not permit of my speaking of any great number of cases referred
to in the remarks which this abstract brings out. I may be per-
mitted to observe, in reference to the operation for carcinoma of
the breast, as I think of it when I began practice over forty years
ago, and now, that it is but another illustration of the impressive
manner in which surgery has advanced. The operation has
become more and more scientific, more and more thorough, as
our knowledge of pathology has increased, and especially would
I emphasize the comfort we have at the present time in hospital
work in being associated with a laboratory where competent ex-
amination of specimens, and original research and investigations
can be made.
Forty years ago, and for many years after, there were few sur-
geons who entered the axillary region and did a complete removal
of its contents.
There were too many surgeons who comforted themselves with
the belief that this axillary involvement was simply inflammatory,
and when once the diseased breast was removed these conditions
would improve and disappear. I may be pardoned for referring
to this feature of the subject under discussion, for I have watched
with so much interest the gradual advances until, at last, we have
so thorough a removal as that which many of us do, and in many
cases, just emphasized and referred to in so scientific a manner by
Dr. Halstead. While it will be noted that in cases of apparently
non-involvement of the axillary glands, based upon careful obser-
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140 VANDER veer: CARCINOMA OF THE BREAST
vation, palpation, etc., yet for years, at the time of the operation,
it has been my rule, in keeping with my method of operating, to
empty the axilla of its lymphatics and contents. Step by step
has it been my privilege to increase the thoroughness of the
operation, so that I am sure if I were to classify my cases in periods
of a half decade each, it would show a marked improvement in
the end results and permanent recoveries.
Regarding the diagnosis I should like to emphasize most
earnestly the importance and wisdom of our impressing upon the
profession at large more thorough Ti^ork in this direction; that
they must not yield to the wishes of the patient that she may not
know of any serious trouble that presents, nor comfort her with
the thought that there is but a simple mastitis to deal with, but
that they must call in consultation the surgeon in whom they
have confidence, and then together, the physician and surgeon,
they can study the case, employing such excellent methods as
have been suggested by Dr. Warren and others, and thus reach as
nearly a positive diagnosis as possible. If the case be non-
malignant in character let the patient have the benefit of the
exhilarating eflfect by lifting her out of the atmosphere of fear of
cancer, which she may have entertained, into the buoyancy of
thought that tells her she has had a careful, thorough examination
and can believe the statements made to her as the result of the con-
sultation. If, however, the consensus of opinion is in the direc-
tion of malignancy, then she should know it, or, a least, her friends,
and I wish to emphasize here, as my own experience, and as that
of many candid surgeons and careful pathologists, that when once
this diagnosis has been made, or there is a suspicion of malignancy,
the earlier the operation is done, and the more thorough and com-
plete it is the better for our patient, and for our statistics, as to
complete reUef. To know that her tumor has been thoroughly