removed, to realize that she has made a good recovery, and to be
assured that the chances are altogether in her favor, is a prognosis
of no mean importance to any patient, whether intelligent or ever
so ignorant. It is something she can forget when there is only a
painless scar to be observed, which disappears gradually; but to
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have present a tumor that is ever in her mind is a depressing factor
that cannot be overlooked. If there is anything in suggestion
upon the nervous system, in these cases, there is no one thing in
which it is possible to do so much good as to impress upon the
patient that she is well, and that she is to forget her past fears.
All her surroundings are to be made such as will eUminate the
fear of a recurrence and return to her former atmosphere of
despondency.
I have thought much as to the incision, when once the operation
is determined upon, and it seems to me that the one which begins
well up in the axilla, almost on an oblique line to a point below
the nipple, thence along the under surface of the breast to the
median line, with a corresponding elliptical incision above, which
traverses the upper segment of the breast area, joining with the
incision just underneath the outer edge of the pectoralis major,
enables me to reach the breast and the lymphatic spaces quite
satisfactorily, even to the removal of the pectoral muscles. This
is an incision that affords good drainage, and will not be greatly
observed by the patient when all is well and recovery has taken
place. I am full of faith in the belief that plastic work for
covering the area from which we have removed a large amount of
diseased tissue, is thoroughly serviceable and I am impressed with
the small percentage of return in the scar, in the fatal cases metas-
tases to internal organs being the principal factor causing death.
The benefit of careful laboratory examination, as to the correct-
ness of diagnosis, in the table this paper presents, is instructive,
comforting, and tends decidedly to the endorsement of the value
that can be placed upon the work of our pathologist.
I quote the following:
Case I. — Mrs. E. S., aged forty-six years.
Operation, May 28, 1902. Fourteen years ago noticed a bunch
in left breast, at the time she was nursing a child. This remained
stationary until three months ago, when it enlarged rapidly and
was very painful. Growth at first had the appearance of a car-
cinomatous tumor, and an incision to aid diagnosis was made.
The pathologist, from the macroscopic appearance, and hurried
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examination made at the time, was in doubt. Thorough removal
was done, and the pathological report from the laboratory later
classed the tumor as an adenoma with lymphangitis.
It seems to me that there is no greater field for the philanthropist
than the endowment of pathologial laboratories for just such work
as this. I am satisfied that there are degrees of maUgnancy and
that there are associations of one form of malignancy with another
that can only be worked out in this manner.
The end results in the 103 cases spoken of in this table bring
out a few points of interest.
Of the hopeless or unfavorable cases, where only a temporary
relief can be afforded, I am satisfied that many are benefited by
an operation, it being well understood at the time, by the patient
and her friends, that it is only to relieve her from suflfering, and
from the distress to which her associates may be subjected in
coming in contact with an ulcer that is likely to be so exceedingly
offensive and difficult to keep in an antiseptic condition. My
experience impresses me with the belief that although such opera-
tions bring little, if any, credit to the surgeon, they do relieve the
patient of much physical and mental distress.
I can say very little permanent good has resulted from the use
of the :v-rays, except the relief from pain it affords. I can endorse
the comfort patients have received from this line of treatment,
and must say that I have seen cases in which hfe seemed to have
been prolonged; but then there is always the element of chronic
carcinoma to be considered when we say that this or that patient's
life has been lengthened by such treatment.
When I consider the treatment of tumors of the breast today,
especially carcinomata, as compared with that of forty-five years
ago, I must endorse the emphatic language in which the layman
expresses himself, i. e,, "What wonderful progress surgery has
made," yet, at the same time, how far short we have come of that
success so much desired, and how selfish for us to appropriate such
an expression when we carefully review the great progress that
has been made in medicine, in the knowledge of cholera, typhoid
fever, and other diseases.
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I fancy that if such men as Parker, March, the elder Gross, the
senior Warren, and others could look in upon an operating-room
today when an operation was being done for removal of carcinoma
of the breast, there would be a look of interest and of surprise not
unlike that to be noted in their expression could they see the
advances made in abdominal surgery at the present time.
Referring to the methods of operation and period of time after
the discovery of the tumor, I would say that in the cases that are
reached early I am not yet convinced that the very radical operation
of removal of the pectoral muscles is called for, but cannot be too
emphatic in impressing upon the yoimger men the necessity of care-
ful examination and dissection of the axillary spaces.
In this report will be noted a few cases where tumor was noted
early in the breast, which did not worry the patient, yet later devel-
oped carcinoma.
Case II. — ^I believe this was the case with Mrs. H. B., aged
forty-three years, and who gave a negative family history, aside
from maternal aunts who had died from tuberculosis. Patient
always well in every respect, with the exception of psoriasis since
twelve years of age. Twenty-three years ago, first noticed small,
hard tumor in right breast above nipple. No known traumatism.
Size increased slowly up to two years ago; some pain, but never
severe. Tumor, size of a hen's egg two years ago, then increased
rapidly and painful. Six months later began to have pain under
arm, and noticed small lump there. Patient in good physical
condition. Examination at hospital showed large, hard mass in
upper half of right breast, one large, and several small nodes in
axilla, and in left axilla is one large indurated gland. Operation
February 26, 1901. Amputation right breast, removal of axillary
glands with pectoralis major and minor muscles, and left axillary
space thoroughly dissected out. Patient left hospital in good con-
dition and has remained well.
These cases are most suggestive. They are the ones in which
we cannot but feel that had the original simple adenoma been
looked after in a judicious manner the patient might later have
escaped the carcinomatous element.
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It is remarkable how unconcerned some patients are in reference
to growths about the manmiary gland, while others, with the very
slightest evidence of some disturbance, become greatly alarmed,
their nervous system receiving a shock that is sad to observe and
detrimental to them when the operating-room atmosphere is reached.
The latter class of patients are often unwilling, even amidst their
fears, to have surgical intervention; yet they are, of all cases, the
most in need and a class we should endeavor to reach early.
The condition of the no-worry patient is in great contrast to
the nervous anxiety of the one who is frightened over the thought
that she is to suflEer from cancer of the breast at some time, and
the years in which this period of worry may be unnecessary, yet
where ultimately a tumor does present.
Case III. — Mrs. E. M., aged fifty-seven years. In its end
results this case has been a most instructive one. In the total
series of cases I began to elaborate, I was greatly impressed with
what I had sometimes been led to call the pre-cancerous state,
from the nervous condition of the patient. Mrs. M., for nearly a
year previous to the discovery of the tumor, came to my office
not infrequently, and while not suffering from direct, character-
istic, lancinating pain, or anything clinically that would demon-
strate a growth presenting, yet was possessed of the fear that she
was to have "a cancer of the breast."
She gave a good family history and was otherwise apparently well.
She would, at times, locate an unpleasant feeling in the right side,
and in order to reUeve her from too many self-examinations I
advised her to wear a diachylon plaster quite continuously, but
she did not forget her condition. In November, 1901, she discov-
ered a small lump in the right breast. I advised a thorough opera-
tion, which was done December 14, 1901, and specimen removed
proved to be. one of scirrhus carcinoma, with metastases to axillary
glands, although the latter could scarcely be felt, on palpation,
previous to the operation. The wound healed kindly and remained
in good condition, but the patient was not relieved of her nervous
strain. She was frightened and in constant fear. About May i,
1902, she was sure that a tumor was developing in her left breast,
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and May 14, to my own distress, I could distinctly map out a small
growth. The patient's mental condition was truly pitiable, but
with a resignation that was heroic she submitted to a second
operation. May 25. In this second operation the pectoral muscles
were removed, ako the axillary glands thoroughly, however, the
microscope alone could detect any invasion of them. From this
operation she recovered, but later had pains and some enlargement
of the cervical glands, and submitted for some time to ^-ray treat-
ment, getting relief from the pain, and at one time felt very much
encouraged. There were no ulcerative growths in the scar tissue.
She seemed fairly resigned to the fate that was inevitable, and
while there were no metastases to the internal organs, or, apparently
to the lung, yet this patient was taken suddenly ill and died, in a
comatose condition, January 13, 1904, from all the evidence of
carcinoma of the brain or membranes.
I would call special attention to the return of the disease, in
some instances later after the first operation. This series of cases
gives some interesting facts as to the time of recurrence.
Case IV. — Mrs. S. A. W., aged fifty-six years, upon whom I
operated for removal of the right breast and axillary glands in 1887,
remained absolutely well until July, 1899, when she noticed a
small tumor in the scar, which gradually increased in size and
became painful. She presented for operation January 17, 1900,
when I did a second operation, and patient has since remained well.
Case V. — ^This is an inoperable case. Mrs. J. M., aged fifty-
six years, upon whom I had operated seven years previously for
carcinoma of the right breast, returned July 3, 1899 for treatment.
Patient had remained well up to within a short time when the
growth appeared, now presenting large nodules involving the
axillary region to a marked degree, and cachexia very pronounced.
Case not in a safe condition for further operative intervention.
Axillary region contained a large, gangrenous, sloughing ulcer.
The shortest period of recurrence is as follows:
Case VI. — Mrs. L. C, aged fifty years, gave the history of
observing a tumor in right breast for two years, then applied for
treatment, and operation done March, 1901. She was well for
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about three months when secondary growths appeared in scar
tissue. First growth not at all painful; second gave great pain.
Second operation done May i, 1901, for removal of the growths
in the axilla and surroimding tissue. Very thorough removal
done at this time. Patient at this operation was very much emaci-
ated and had a growth in the axilla about half the size of a hen's
egg. She made a good recovery from this last operation, and when
last heard from was in good health. Laboratory report as follows :
Recurrent carcinoma of mammary region.
* Case VII. — ^Mrs. A. E. H., aged fifty-one years. Amputation
of right breast August, 1903. Growth returned March, 1904.
I did a second operation May, 1904, removing all scar tissue,
together with subclavicular and axillary glands. Patient made
a good recovery, and so far as I am able to state has remained well
since.
Regarding the element of pain it is not always so pronounced
or marked imtil the tumor takes on an active stage of increase.
Case VIII. — Mrs. E. H., aged sixty-five years. History of
cancer on paternal side. Patient always well. Menopause two
years ago. Five years ago noticed small, movable bunch in upper
portion of left breast. No pain or soreness except a little toward
axilla. Increase very gradual until past six months, since which
time growth has changed position to around the nipple, which is
retracted.
Operation, May 24, 1904. Tumor, with axillary glands, entirely
removed. Pathological report confirmed diagnosis. Good re-
covery followed. Careful study of this question impresses one
with the knowledge that when an operation is done before involve-
ment of the axillary region a better percentage of recoveries follows.
Case IX. — Miss L. K., aged fifty-nine years. In 1900 was oper-
ated upon by a surgeon who did not think it necessary to remove
the axillary glands. In October, 1901, a tumor presented in the
axilla and scar tissue. January, 1902, she first consulted me, at
which time growth in axilla and scar were considered inoperable,
and x-idcy treatment employed with benefit in relieving pain and
reducing tumor in size, but did not result in permanent relief.
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In the table^of operations there are two cases of metastasis to the
long bone.
Case X. — ^Mrs. M. C, aged fifty-seven years, a large woman,
well developed and much adipose tissue. General health not
affected and patient much opposed to operation with knife.
Trouble began January, 1901, when growth in right breast was first
noticed, which gradually increased, but no marked pain. Patient
took various treatments, including :c-ray and injections hypoder-
mically. June 17, 1902, she presented with a large tumor in-
volving the right breast, with axillary glands enlarged and causing
her much distress from pressure of the arms upon them, against the
chest. I did a very thorough operation, removing the pectoral
muscle, the subclavian glands, and to close woimd brought up
flaps from the side and surface of the abdomen. Patient made a
good recovery and left the hospital in excellent condition. Labora-
tory report on specimen as follows: Scirrhous carcinoma with
metastases to lymphatic glands. This patient continued in good
health, with the exception, at times, of complaining of pain in
region of and underneath the scapula, and of some swelling of
right arm. This disappeared in time; she was able to attend to
her household duties and remained well until the summer of 1905,
when she showed more marked cachexia, but no appearance of
metastases could be discovered. The original scar was in excellent
condition. About the first of August, in getting up from bed one
morning she suddenly collapsed, and upon being taken up and
placed in a chair it was found she was imable to use her left leg.
She was brought to the hospital, and examination revealed a frac-
ture of the upper third of left femur with the evidence of carcinoma
being present. She also complained of pain in her left chest,
and on examination there was found quite a pleuritic effusion.
Patient was placed in bed, the limb properly dressed, bowels
and kidneys carefully watched, and for four weeks she improved,
but finally died from all the evidence of carcinoma of the pleura,
possibly of the lung, on the left side.
I have been greatly impressed in the cases in this table that have
come to me, in which there was a well-defined carcinoma of the
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breast and also fibroid tumors of the uterus. In these cases I
have operated for both conditions, cases generally doing well,
but there is a greater degree of anxiety to the surgeon. Again,
in others, I have only removed the breast, and these patients seem
to Uve on very comfortably for many years, with no apparent dis-
turbance from the uterine fibroid. Patients who have passed the
menopause do best.
The element of traumatism in carcinoma of the breast has ever
commanded my careful thought. Is it a factor? We must heed
the history of such cases as the following:
Case XI. — ^Miss D. P., aged forty-two years, who gave a very
unusual history. In October, 1902, she presented with a history
of a gradually developing tumor, which followed traumatism of
the right breast. Patient had struck against a chair in January,
1902, and hurting herself. May, 1902, she noticed marked pain
over the region of original injury. Tumor now about the size
of an orange, painful, movable, and with axillary involvement.
Operation done, axillary space thoroughly cleaned out, and patient
made a good recovery. At this time we also removed a uterine
polypus, which laboratory reported non-malignant in character.
Growth removed from breast was reported carcinoma, with
papillomatous changes of nipple and metastasis to axillary lymph
nodes. She made a good recovery, gained in flesh and in every way
felt herself thoroughly well until February, 1906, when she was not
so well, having a marked pain in left side. She presented for
examination February 21, 1906, when a diagnosis of pleurisy
with effusion was made, chest was. aspirated and three pints of
serous fluid were removed. At this examination her family
physician. Dr. Larkin, discovered a hard mass associated with the
left breast, which the patient said she knew very little about.
Nipple was retracted, mass movable, very hard, scirrhous in char-
acter and axillary glands also involved. Following further effusion
a second aspiration was done and about sixteen ounces of fluid
removed.
The patient recovered, and was so encouraged, and expressed
such a strong desire for removal of the breast that an operation
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was done June 2, 1906. She made a steady, uninterrupted
recovery from all of her ills and in every way it was a successful
case.
She returned home but later had further attacks of pleurisy
and died, evidently, from metastasis of the pleura, about six
months after the second operation. This case illustrates the
cancerous diathesis most earnestly.
It is a matter of interest in our patients who are exceedingly
fleshy, to note the difficulty that sometimes exists in reaching an
early diagnosis, but I have an impression that these patients are
very susceptible to the least disturbance about the glands and a
pain,, be it ever so slight, attracts their attention at once. A
clinical diagnosis is not always so easy.
Case XII bears upon this point. Mrs. S. C, aged thirty-four
years. Family history strongly cancerous, several members
having died from this trouble, including her mother, and this his-
tory was a source of great anxiety to her. July, 1902, first noticed
lancinating, characteristic pain in right breast, and six weeks
ago noticed a tumor. Axillary glands involved. Prompt operation
was done January 25, 1903, believing, from the clinical history
that this patient was suffering from acute carcinoma of the breast.
She weighed two hundred pounds. Thorough removal was done
and report from the laboratory showed growth to be a cystic fibroma
of breast with lympho-adenitis.
It is very instructive to note how short a time sometimes elapses
in the period that a tumor is apparently developing.
Case XIII. — ^Mrs. B. M., aged sixty-five years, three months
previously had slight pain in left breast. Now there is a tumor
size of a pigeon's egg which has grown rapidly. Not much loss
of weight or strength. When patient presented for examination
and treatment growth was ulcerated, rectangular in shape, and
measured 17 x 12 cm., seemed movable with a very offensive
odor, and glands of axilla involved. Thorough operation was
done November 12, 1902, and patient made a good ifecovery.
Pathological report from laboratory: Very cellular, medullary
carcinoma.
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The following cases, giving a tuberculous history, are impressive:
Case XIV. — Mrs. A. L. W., aged thirty-seven years. This
case arouses the s)mpathy of the surgeon. She gave a family
history of most pronounced tuberculous trouble, and had had
some early lung affection herself. In the beginning of 1903 she
discovered a small growth in her right breast, which alarmed her,
but of which she said very little to her family. At first it developed
very slowly, but later, with slight, characteristic, lancinating pain it
began to grow more rapidly. She lost in appetite and weight and
presented the appearance of a patient much worried about herself.
When she came to my oflBice, December 29, 1903, 1 told her husband
and herself that she imdoubtedly had cancer of the breast and that
an immediate operation was advisable. To this they readily
consented, although they had been advised differently. The opera-
tion, December 31, 1903, was a most serious one involving about
three inches of the axillary vein, which I was obliged to dissect out
and ultimately ligate the axillary artery, resecting a portion of
it with the tumor. The nerve supply was preserved. The col-
lateral circulation was suflScient to maintain life and no gangrenous
Spots appeared, yet great coldness of the arm in the healing of the
wound. No radial artery could be made out after her recovery,
although she got the use of her hand and forearm very well. The
wound remained in good condition for about eight months, when
a slight nodule appeared in the upper portion of the scar. She
now returned to the hospital and had a most complete, thorough
application of the :v-rays with a disappearance of the nodule, the
suffering and indurated tissue, and the swelling of the arm, so that
the patient really felt very much better; however, the same condi-
tions returned in other portions of the cicatrix and a second opera-
tion was done October 28, 1904, for removal of the secondary
deposits, a plastic operation performed, and patient made a verj^
good recovery. She gained somewhat in flesh and was most
hopeful that she might ultimately get well. She was faithful
and earnest in her treatment, aiding her recovery in every way
possible. I occasionally heard from her, and on April 15, 1907,
her husband wrote me that the case had not changed materially
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in a long time, although she was gradually growing weaker. No
tumor had developed to any extent nor was there evidence of metas-
tases. The great complaint was the immense swelling of the right
arm, which gave her a good deal of pain.
Surely this case is one that has shown a degree of malignancy
and yet a power of resistence on the part of the patient most
remarkable to observe.
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FINAL RESULTS IN 164 CASES OF CARCINOMA OF THE
BREAST OPERATED DURING THE PAST
FOURTEEN YEARS AT THE AUGUS-
TANA HOSPITAL.
By a. J. OCHSNER, M.D.,
CHICAGO.
In order to condense the study of these 164 cases sufficiently to
prevent this report from becoming altogether unwieldy, it has seemed
best to make the following tabulations which were compiled by
my associate, Dr. N. M. Percy, from the case histories. The
present condition of 98 patients was determined by correspondence
with patients and with their physicians, or by personal examination.
From 63 cases no information has been obtained as yet, but only
twenty letters have been returned unopened, consequently it is
fair to suppose that further information can be obtained concerning
the condition of some of the 63 cases not heard from.
Of the 98 cases, concerning which we have received reports,
54 cases are still living and all of these with two exceptions are at