ideal.
Occasionally, and happily with increasing frequency, an inci-
sion for diagnostic purposes has to be made. Great care should
be exercised to make these exploratory cuts no deeper than is abso-
lutely essential. Very rarely is it necessary to carry the knife
into a cancer, for on exposure of the subcutaneous fat the tell-tale
drawing of the fibrous tissue is revealed; sometimes the fat must
be cut into for a little distance. If the growth is not malignant
the incision should usually pass through it.
Caustics. I am indubitably convinced that the local and
regionary recurrences after incomplete operations, which come,
as a rule, with amazing rapidity when the knife has been used, are,
to say the least, relatively late in making their appearance when
chemical or actual cauterization has been employed. I have sev-
eral times had occasion to operate upon cancers which had been
vigorously and repeatedly treated with caustics, and to note the
comparatively admirable condition, the freedom from cancer per-
meation, of the surrounding tissues and of the axilla; whereas,
after incomplete operations with the knife the local manifestations
of recurrence were almost invariably deplorable and the prognosis,
of course, invariably hopeless.
It was my practice at one time in making the exploration in
doubtful cases to excise a portion of the breast tumor with the
Paquelin cautery to prevent the wound inoculation which I feared
might take place if the knife were used. The excision of a Speci-
men for macroscopic or microscopic examination is never resorted
to except just before operation. If tiie actual cautery for any
reason is not used, the wound is immediately cauterized with car-
bolic acid. All incomplete operations for cancer should, when
feasible, be made with the Paquelin or actual cautery.^ The
* I was greatly pleased to note, during a recent visit to Rochester, Minnesota, that
Drs. William and Charles Mayo make extensive use of the actual cautery in opera-
tions upon cancers incurable by the knife, and to have them indorse the view, so
long maintained by me, that there is relative immunity from local metastasis with
the employment of the cautery.
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78 halsted: cancer of the breast
Paquelin is ideal for the removal of cutaneous nevi, particularly
of the melanotic variety. I doubt if any melanotic tumor of the
skin should be removed with the knife.
Cancerous Axillary Glands, with Non-demonstrable Cancer
of the Mamma.
I have twice seen extensive carcinomatous involvement of the
axilla due to mammary cancer, which latter in neither instance
became palpable or demonstrable for a considerable period after
the axillary glands had attained conspicuous dimensions. In
each case the "axillary tumors" had been removed, in one of them
a year before, and in the other perhaps two years prior to my first
examination, which, though made in the most careful manner,
failed to find the slightest evidence of cancer of either breast. In
the course of a few months thereafter the mammary disease mani-
fested itself in both patients.
A third patient was operated upon, for enlarged glands of the
axilla, about two and one-half years before she consulted me
concerning the local axillary recurrence of the disease, and
more especially to be relieved of severe neuralgic pains in the
arms and legs. In this woman I found a large mass of axillary
glands, which proved to be cancerous; but nothing in the breast
except a quite definite parchment-like induration at the base of
the nipple, which was retracted not at all, or merely to a barely
appreciable degree. With performance of the complete breast
operation the pains in the extremities, which distressed her greatly,
vanished.
Disseminated Pains, which Would Seem to be Caused
Occasionally by the Toxins Generated in the Course of
THE Growth of Cancer. Distressing pains in the knees, the legs,
the back, the arms, so severe and so located as to suggest cancerous
involvement of the vertebrae, have in two cases operated upon by
me at the Johns Hopkins Hospital disappeared on removal of the
growth, which in one instance was large, ulcerous and foul-smelling;
in the other (the case cited at the end of the preceding paragraph)
consisted merely of a large mass of glands in the axilla.
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halsted: cancer of the breast 79
Reactionary Edema in Mammary Cancer. Quite recently I was
privileged to see a condition of board-like edema, limited, in a gen-
eral way, to the pectoral region of one side. There was no defi-
nitely appreciable abnormality of the mamma other than the
edema, in the area of which it was included; otherwise, not until
perhaps six months after the first manifestation of this edema was
there the least evidence of neoplastic disease of the breast. Then,
as, in my experience, is usually the case in the presence of extensive
and great edema of reaction, the cancer made very rapid strides.
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THE RESULTS OF OPERATIONS FOR CANCER OF THE
BREAST AT THE MASSACHUSETTS GENERAL
HOSPITAL FROM 1894 TO 1904.
By ROBERT B. GREENOUGH, M.D.,
CHANNING C. SIMMONS, M.D.,
AND
J. BELLINGER BARNEY, M.D.,
BOSTON.
At the request of Dr. R. G. Le Conte, the Secretary of the Ameri-
can Surgical Association, and of Dr. J. Collins Warren, and with
the assent and approval of the surgeons of the hospital, the writers
have attempted to trace and to report the cases of cancer of the
breast which entered the Massachusetts General Hospital during
the ten-year period from January i, 1894, to January i, 1904. The
latter date was selected in order that a period of at least three years
should have elapsed after operation in every case. It is with great
pleasure that the writers acknowledge their appreciation of the
cordial cooperation they have received from all of the members of
the Hospital Stafif, and especiaUy from the administrative officers
of the hospital, who have contributed much to the success of this
rather arduous undertaking.
The Massachusetts General Hospital may be taken as a type of
the larger American general hospitals where operations are per-
formed by a considerable number of surgeons, each one being on
service for only a small portion of the year; in contrast to the spe-
cial or university hospitals, where one surgeon is continuously on
duty for many years, and specialization in the different branches. of
surgery is a possibility. It is to be supposed that the statistics of
the general hospitals can never equal those of the special hospital;
but it is fair to say that they do represent more accurately the
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GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST 8 1
average results of surgery in a given community, and thus give,
perhaps, a more correct indication, from the patient's point of
view, of the average expectation of cure. The 416 operations of
this series were performed by twenty different surgeons,* and the
greatest number performed by any one surgeon was 51.
The methods employed in tracing cases were those which have
proved efficient in other investigations. The hospital record of
each case was first abstracted on a card of convenient size. (See
figure.) These cards were numbered consecutively, and re-entries,
out-patient records, and letters from patients, were attached. A
letter was then sent to each patient or to her friends. When no
reply was received from patients or friends, letters were sent to
attending physicians, postmasters, police departments, city and
town clerks, and Boards of Health. Many of the fatal cases were
found in the excellent records maintained by the Massachusetts
State Board of Health, and a few from the Bureaus of Vital Sta-
tistics of other New England States. Finally, a certain number of
cases were traced by personal interview with neighbors, relatives,
and friends; by reference to city directories and by the use of
registered letters, 378 of the total 416 (or over 90 per cent, of the
cases) were followed to a definite end-result, and the writers feel
compelled to acknowledge that without the courtesy and cooper-
ation of many persons whose interests were in no way involved,
this report could not have been prepared. In making a study of
hospital records, it is essential that a uniform interpretation be
placed upon the data obtained.
The record of the operation performed in each case was studied
and the operation was classed in one of the four following groups :
I. Complete Operations. In which the tumor, the breast, the
sternal portion of the pectoralis major muscle, and the entire
axillary contents were removed, and the pectoralis minor muscle
either divided or removed. Exploration above the clavicle was
* Drs. C. B. Porter, J. C. Warren, John Homins, H. H. A. Beach, A. T.
Cabot, J. W. Elliot, M. H. Richardson, F. B. Harrington, S. J. Mixter, W. M.
Conant, C. L. Scudder, J. G. Miimford, W. A. Brooks, Jr., C. A. Porter, F. G.
Balch, G. W. W. Brewster, Farrar Cobb, E. A Codman, R. B. Greenough, and
D. F. Jones.
Am Surg 6
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82 GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST
not considered essential. This interpretation of the essentials of a
"complete" or "completed" operation was accepted as the opinion
of a majority of the visiting surgeons of the hospital.
2. Semicomplete Operations, Those in which the whole of the
comJ)lete operation was done, with the exception of the division or
removal of the pectoralis minor.
3. Incomplete Operations. Those in which an attempt at radi-
cal cure of the disease was made, but the pectoralis major, a
portion of the breast or of the axillary contents, or other parts
essential to the complete operation were left behind.
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GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST 83
4. Palliative Operations. Those in which no hope of radical
removal of the whole disease was entertained, and cancerous tissue
was supposed to remain in the wound at the end of the operation.
It has been the custom of the hospital since 1885 for all material
obtained at operations to be examined by a clinical pathologist,
Dr. W. F. Whitney. The pathologist's report is filed by the
house ofiicer, and bound up with the patient's clinical record; but
reports are sometimes lost. Of the 376 cases which form the basis
of this report, in 39 no pathological report was found. In 337
cases the report of the gross and microscopic examination of the
tumor (and usually of the axillary and supraclavicular glands,
when removed) was present. It is probable that a pathological
examination of every case was made.
In the interpretation of causes of death and their relation to pos-
sible recurrence, the writers have endeavored to err on the side of
safety, and to accept no case as dying free from recurrence which
was not above reproach. For this reason, 28 cases dying of "apo-
plexy," "paralysis," "multiple neuritis," "pleurisy," "pneumonia,"
"inanition," "gastro-enteritis," etc., have been arbitrarily assigned
to the "died with recurrence" class. The 7 cases which have
been admitted to the "died without recurrence" group will be
discussed in detail in another place. Two patients who died
within three years of operation, of diseases other than cancer, have
been thrown out entirely as giving no data of value in determining
the success of the operation. In this way a uniform interpretation
of results was obtained, which, it is to be hoped, may be employed
in the publication of statistics of other series of cases.
The information with regard to the 64 cases, here reported as
alive and well, was obtained from the following sources: Letters
from the patient were accepted as evidence in 38 cases where the
patient lived too far away to come to the hospital for examination.
Letters from acquaintances and relatives were received in 5 cases.
Letters from physicians were received in 8 cases, and 13 patients
came to the hospital for examination.
During the ten years from January i, 1894, to January i, 1904,
613 cases of breast cancer were entered on the records of the
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84 GREENOUGH, SIMMONS, BARNEY; CANCER OF THE BREAST
Massachusetts General Hospital. Of this number 416 were cases
of primary operation; 80 were re-entries of the above 416; 52 cases
were discharged untreated, by or against the advice of the surgeon;
45 were patients first operated upon elsewhere and admitted for
recurrence; and 20 were cases operated upon in the Massachusetts
General Hospital before 1894 and readmitted with recurrence.
Table I.
1894-1903, inclusive.
Primary operations 416
Re-entries .80
Untreated 52
Recurrence from operation elsewhere 45
Recurrence from operation before 1894 20
Total cases 613
Of the 416 cases of primary operation, 376 were traced to a
conclusive end-result. 38 could not be traced, and in 2 cases the
results were inconclusive.
These 376 end-results have been divided into 5 groups as follows:
Table II.
Year.
itotfti
for year
Total {Per cent, tree from recar-
free of ; rence inclading pallia-
recur* < tive cases and deaths
rence. | from operation.
1894
1895
1896
1897
1898
Total for 5 years,
1894-1898, in-
clusive.
1900
1901
1902
1903
Total for 5 yean,
1898-1908» in-
clusive.
Total 10 years,
1894-1908, in-
clusive.
8
2
10
5
4
24
11
, 27
I *^
I 32
25
27
82
44
51
82
84
^ I
4
152
»
1
28
2
32
28
...
14
198
88
88
40
40
27
28
7
8
6
10
12
I 14.5 per cent, (omitting
palliative operations
= 16 per cent).
40
1
6
4
»
180
188
64
8 1
1
15
7
282
876
48
71
: 28.5 per cent (omitting
palliative operations
= 26 per cent.).
18.8 per cent, (omitting
palliative operations
I = 20.9 per cent).
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GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST 85
The 64 cases reported alive and well have aU passed the three
year period without evidence of either local recurrence or internal
metastasis, with the single exception of i case. This case had a
recurrence in the axillary portion of the scar two years after the
primary operation; the recurrent nodule was removed four years
and eight months ago, and has not returned. The duration of
life of these 64 cases is as follows:
Table III.
Duration of Life in 64 Cases Alive and Well,
3-4 years 9 cases
4-5 **
5-6 "
6-7 "
7-8 "
8-9 "
13
10- 1 1
5
11-12
6
12-13
7
13-14
3
9-10 years 4 cases.
8 "
..... 6 "
2 "
I "
43 " I 21 "
Average of 64 cases equals 6 years and 10 months.
The oldest patient in this group was seventy-six and the youngest
twenty-nine years of age. The consideration of the prognostic
importance of the age of the patient, the duration of the disease
and its situation in the breast will be taken up in connection with
the data obtained from the study of all five groups.
Disability. It has been most gratifying to observe how little
disability was produced, even by the most complete operation,
when both of the pectoral muscles were removed. Reports upon
this point were given in 53 of the 64 cases: 26 had "full" or
"perfect" use of the arm, 20 had good use, 4 "fair," 2 only "a
little," and in i case, in which sepsis and erysipelas occurred
after operation, the arm was described as "stiff." It has been our
experience that the functional impairment of the shoulder, which
may be pronoimced immediately after operation, disappears during
the first and second year, and rarely causes any difficulty after that
time. With regard to swelling of the hand and arm, as a result
of the dissection of the axillary lymphatics and obstruction to the
axillary veins, the results were found to be less satisfactory. In
48 cases information upon this point was available, and in 17 of
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86 GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST
these cases swelling of the hand or arm was spoken of. It is prob-
able that swelling of the upper arm is to be regarded as the direct
result of the removal of the axillary lymphatic trunks; but swelling
of the hand and fingers may probably be attributed to cicatricial
pressure upon the vein. It is reassuring, however, to find that
swelling of the arm occurs so commonly in cases without recur-
rence; and that it is not to be regarded necessarily as evidence of
axillary recurrence.
Alive with Recurrence. Eight cases. Six of which have recur-
rent nodules in the scar, one in the spine and one in the ribs. The
length of life, after the original operation in these cases, is as
follows:
Table IV.
3- 4 years i case.
4-5 " I "
6- 7 " 2 "
7- 8 " 2 "
lo-ii " 2 "
One of the patients operated upon eleven years ago for colloid
cancer had recurrence immediately after operation, which has
slowly increased in size up to the present time, but has not yet
been operated upon, causes no disability and has shown no evi-
dence of generalization — a relatively non-malignant cancer. Two
of the alive, with recurrence, cases are examples of so-called "late"
recurrence — one being a case of adenocarcinoma, free from recur-
rence for seven years, and then developing symptoms of spinal
recurrence; the other a case of medullary cancer, examined and
found free from recurrence six years and nine months after opera-
tion, but developing a recurrence in the scar before the next report
six months later.
Died without Recurrence, Seven cases died without signs of
local or internal recurrence at a period more than three years after
operation. These cases were as follows :
Two died of **debility and old age,'* at seventy-one and seventy-
four years of age; nine years, and seven years and eight months,
respectively, after operation. Two died of "consumption" — four
and one-half and five and one-half years after operation. One
case died of apoplexy six years after operation. This case was
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GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST 87
not classed as an example of cerebral metastasis, as the patient
was seventy-eight years of age, and had had already one attack of
cerebral hemorrhage with almost complete recovery, three years
before.
One patient died of acute renal disease four years and three
months after operation, and was reported by her physician as free
from local or internal recurrence, and the last of the 7 cases died
of acute lobar pneumonia in the hospital four years and four
months after operation, and a complete autopsy revealed no evi-
dence of carcinoma.
Died of Operation. Fifteen cases died as an immediate result
of the operation — 14 in the hospital and one inunediately after
leaving. This gives an operative mortality of 15 in 416 cases —
3.6 per cent. Eleven of these deaths occurred in the first five-
year period, out of 215 operations (5.1 per cent.), and four deaths
in the last five-year period (2 per cent.).
The causes of death were as follows :
Pneumonia 6
Pulmonary embolism a
Hemorrhage and shock 4
Sepsis 3
The pneumonia cases occurred during the months of March,
April, Jime, and August. Three of the 6 pneumonias were in sep-
tic cases, and may possibly have been of embolic origin. Two of
the pneumonia cases came to autopsy. Of the three deaths from
sepsis, 2 were due to erysipelas.
Died with Recurrence. Two hundred and eighty-two patients
died with symptoms of local or internal recurrence. Of this
number 254 are reasonably certain to have had return of the disease,
while 28 cases have been classed as probable recurrence, though
not entirely beyond dispute. These cases were referred to in the
beginning of the paper, and it was stated that it was our intention
to err on the side of safety, and to class as recurrences all cases
that were not above reproach. The causes of death given in the
28 disputable cases are as follows :
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88 GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST
Table V.
28 Cases Dead with Probable Recurrence.
Doratlon aAer operation.
Number of
Arteriosclerosis*
Paralysis and apoplexy*
Meningitis ....
Brain tumor
Heart and kidney disease
Cardiac hypertrophy .
Cardiac insufficiency
Mitral stenosis .
Pneumonia ....
Consumption
Bronchitis ....
Pleurisy .....
Gastro-enteritis .
Dysentery ....
Cancer of uterus .
Multiple neuritis
Erysipelas ....
Inanition ....
Yeare.
I
o
I
2
3
3
7
II
I
o
3
o
o
2
Months.
II
9
5
S
o
2
7
o
2
9
7
5
6
3
(3-2) (0-3) (0-7) (0-3)
(2-7) (1-3)
7
4
3
5
I
10
o
II
28
Seven of these doubtful cases are known to have passed the
three-year period without local recurrence in the scar.
With regard to the remaining 254 cases, dead with recurrence,
a more detailed account will be given imder the heading of recur-
rences. It is sufficient here to say that of the whole 282 cases
dead with recurrence, the recurrence was local in the scar in 120
cases, and no recurrence in the scar was present in 65 cases. In
the other 97 cases data upon this point were not obtainable.
The total number of cases free from recurrence over three years
after the operation is obtained by adding to the 64 cases alive and
* The 8 cases of "apoplexy," "paralysis," and "arteriosclerosis" died at 36, 62 ,
69, 70, 75, 76, and 77 years of age, respectively.
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GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST 89
well the 7 cases which died of other diseases without signs of
recurrence over three years after operation — ^a total of 71 cases in
which the operation may be presumed to have been successful.
In view of the possibility of late recurrence, however, we do not
wish to describe these cases as "cures."
The statistics for successful operations at the Massachusetts
General Hospital for the ten-year period are thus: 376 cases of
primary operation for breast cancer, with 71 cases free from recur-
rence three years or more after operation — 18.8 per cent. (This
includes palliative operations and deaths from operation.) Fifty-
six of these cases had only palliative operations performed, and
although 4 of these palliative operations were unexpectedly suc-
cessful, they should not be counted in an estimate of the success
of operations for radical cure of the disease. Leaving out the
palliative cases, therefore, but retaining the cases which died of
operation, we have 320 cases of radical operation with 67 success-
ful results — 20.9 per cent, for the whole ten-year period. The
results during the last five-year period, when the more extensive
operations have been performed, are better than those from 1894-
98, inclusive. During the first period there were 160 operations
for radical cure, with 26 successful results — 16.2 per cent. Dur-
ing the last five-year period, from 1899-03, inclusive, there were
157 operations for radical cure, with 41 successful cases — or 26
per cent. It should be noted that the 15 cases of death due to
operation have been counted as unsuccessful cases in these esti-
mates, and have not been taken out from the entire number, as
has been done in a certain number of other reports upon the end-
results of cancer operations. We have wished to give a fair esti-
mate from the patient's point of view, and to the patient the opera-
tion is equally a failure whether it causes her death immediately
or fails to remove the whole of her disease. Such facts as we have
been able to collect will be arranged under four main headings :
1. Extent of involvement.
2. Variety of cancer.
3. Duration of the disease.
4. Magnitude of the operation.
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90 GREENOUGH, SIMMONS, BARNEY: CANCER OF THE BREAST
The extent of involvement is perhaps the most diflScult point to
determine, from a clinical point of view, as the symptoms do not
invariably agree with the underlying pathological conditions. We
have not attempted to make any study of the size of the tumor,^ as
stated in the clinical examination of the patient, as these data
were considered to be of significance only in connection with the
variety of cancer present. The extent of involvement has been
considered under the following headings:
1. Adherence to skin.
2. Adherence to chest.
3. Enlarged glands in axilla.
4. Enlarged glands in neck.
5. Cancer of both breasts.
6. Cancer of special anatomical structures.
7. Ulceration.
Adherence to Skin. Clinical records with regard to the adher-
ence of the tumor to the skin were given in all but 41 cases. The skin