522 MR. THOMAS JONES AND MR. JOHN E. PLATT: CANCl.li, OF THE, BREAST.

THE RESULTS OF OPERATIONS FORCANCER OF THE BREAST.

BY THOMAS JONES, B.S., F.R.C.S.,SURGEON TO THE MANCHESTER ROYAL INFIRMARY AND PROFESSOR OF

SURGERY IN THE OWENS COLLEGE;

AND

JOHN E. PLATT, M.S., F.R.C.S.,RESIDENT SURGICAL OFFICER, MANCHESTER ROYAL INFIRMARY.

BEFORE a correct estimate of the true value of any opera-tion can be formed it is necessary to consider the ultimateresults with which it is attended. It is not enough to knowwhat the immediate risks of its performance may be ; weshould also find out what are likely to be its remote effects.It seems to us that hardly suflicient stress is laid on this

matter, and that we are too apt to be satisfied if the imme-diate results come up to expectation. These remarks

apply with peculiar force to the operations performedin cases of malignant disease, and it is very pos-sible that if we were more thoroughly acquaintedwith the late results of operation in such cases we

might pause before we recommended our patients tosubmit to them. The accompanying table deals with all thecases of carcinoma of the breast which were operated uponby Mr. Jones at the Manchester Royal Infirmary during aperiod of ten years (1883 to 1892 inclusive). It givesparticulars of the cases when they first came under observa-tion, and also records the results of our inquiry into theirafter-history. This inquiry has been a work of considerabledifiiculty and labour, as anyone who has been engaged insimilar work will know ; the patients have been widelyscattered, and difficulties have arisen from changes ofresidence and from many other causes. The table includes55 cases, of which more or less information of the

after-progress was obtained in 52 cases. In spite, however,uf all our efforts we were unable to learn anything moreabout the remaining 3 cases. In the present paper wepropose to deal in the first place with certain points whichare illustrated by the histories given and the symptomspresented by the patients at the time they first came underobservation ; secondly, with the results of our inquiry intothe after-progress of the cases ; and, thirdly, with certainconclusions which we have deduced from a careful study ofthe facts now before us.From an analysis of the cases we obtain the following

particulars with regard to sex, age, family history, &c.All the 55 patients were women ; no examples of cancerof the male breast have come under observation duringthe period under consideration, Seven patients were

between the ages of thirty and forty, 30 between fortyand fifty, 12 between fifty and sixty, 5 between sixty andseventy, and 1 was over seventy years of age. The greatmajority-more than half the cases-were thus betweenforty and fifty, the period of life at which cancer generallyis most frequently met with. In 23 of the 55 cases the rightbreast was affected by the disease, in 29 the left breast,whilst in the remaining 3 cases the notes give no informationupon this point. The nature of the growth was in all casesscirrhous ; 2 were examples of atrophic scirrhus. A familyhistory of malignant disease was obtained in 7 cases only(12’7 per cent.). In our table we have an account of amother and daughter and the mother’s sister suffering fromcancer. The mother’s sister (No. 3 in the list) is still livingand free from recurrence, although the operation took placeeleven years and three months ago. A history of previousbreast troubles was given in 11 cases (20 per cent.). Therehad been abscess in 5, sore nipple in 3, sanguineous dischargefrom the nipple in 1, "broken breast after confinement

(probably abscess) in 1, and severe pain in the breast duringsuckling in 1. From this it appears that cancer is especiallyliable to occur in breasts which have been previously affectedby abscess or other disease. A history of injury to the breastwas obtained in 8 of the 55 cases. As to the duration ofthe disease before the patients came under observation,so far as we could learn the disease had in 11 cases beenin existence for less than three months before operation, in

9it had existed from three to six months, in 6 from six tonine months, in 15 from nine to twelve months, and in 9from one to two years, whilst in the remaining 5 cases theduration is doubtful. It must not be forgotten, moreover,

that the onset of cancer of the breast is usually insidiouiand that, the disease has made very considerable progressbefore it is noticed by the patient. Frequently she discoversa tumour of large size whose presence has hitherto remainedunsuspected. The great length of time which often elapsesbetween the discovery of the tumour and the time the

patient seeks advice is worthy of notice, since it allowthe disease to become much more extensive and thusnecessitates a more formidable operation and greatly in-creases the chances of recurrence. In 32 of the 55 cases thefirst symptom noticed by the patient was the presence of a" lump" in the breast, in 8 pain was the first symptom, andin 7 retraction, of the nipple. In 1 case the patient noticedthat the axillary glands were enlarged before she observed anyswelling in the breast, and in 2 failure of the general healthled to the discovery of the local disease. With regard to thestate of the skin over the breast, in 34 of the 55 cases the.skin was adherent to the tumour, in 10 of these being(listinctly infiltrated by the new growth, and in 1 ulcerated.Several other cases showed dimpling when the overlying skinwas pinched up between the fingers. The nipple was re-tracted in 37 cases, unaltered in 14, whilst its conditionwas not recorded in 4. In 2 patients it was ulceratedand in 2 the disease was preceded by inveterate eczema(Paget’s disease). The axillary lymph glands were di’s-

tinctly enlarged in 47 cases, apparently uninvolved in

7, and the glands along the pectoral muscle were alone-involved in 1. It is very significant (and this has an

important bearing on a point of practice which we wishto emphasiae) that in 7, or nearly one-eighth, of our

cases no enlargement of the axillary glands could befelt before operation, and yet enlarged glands were

discovered when the axilla was opened. This provesthat it is never safe to conclude that no enlargement ofthe axillary glands exists unless the examination of thespace is conducted through the wound. This is espe-cially trne of those cases in which the axilla contains anabundance of fat, under which circumstances small shottyglands may, and very often will, elude detection. Thesupra-clavicular glands, in addition to those in the axilla,were slightly enlarged in 4 cases, and in these a speedyrecurrence of the disease took place after operation; indeed,the operations in these cases were incomplete, as all theinfected glands could not be removed. It would have beenbetter if these 4 cases had been left untouched; they weremanifestly unfit for operation.

Itesolts cf operation.-The ultimate results, so far as wehave been able to learn, are as follows :-

Deaths soon after operation ............... 2Patients who have died without recurrence ... 2-

" " , from recurrence ...... 34" now living with recurrence ......... 8" .. and free from recurrence ... 6

No further information obtainable............ 3

55Of the 2 deaths which occurred whilst the patients were inhospital 1 (Case 42) took place eight weeks after opera-tion from chronic bronchitis and dilatation of the heart.We think that this death ought not to be put down to theoperation, since the patient recovered from its immediate-effects and progressed favourably until shortly before herdeath. The other patient (Case 1) died four weeks afterremoval of the breast from septic absorption from the

granulating surface on the chest wall. In this case it was.necessary to sacrifice much of the skin over the breast, and alarge raw surface was left ; at the time there were severa]extensive burns with profuse septic discharge in the sameward. With regard to the technique of the operation the’axilla was opened and infiltrated glands removed in 47 of the’55 cases, and it was not opened in 7. Unfortunately, thenotes of the remaining case are very imperfect and do notgive any information upon this point. In one case theaffected glands so completely surrounded the axillaryvein that a portion of the vessel had to be sacrificed, yet nainconvenience beyond a temporary cedema of the arm wasexperienced by the patient. In 4 cases only was it deemednecessary to remove a portion of the pectoralis major owingto the extension of the growth to the muscle. In 1 case’

(No. 37) the tumour, which was situated near the axillaryborder of the mamma, was excised with some adjacent tissuewithout taking away the entire breast. This is a method ofoperating strongly to be deprecated ; it was followed byspeedy recurrence of the disease which necessitated a secoad

523MR. THOMAS JONES AND MR. JOHN E. PLATT: CANCER OF THE BREAST.

OPERATIONS FOR CARCINOMA OF TUB BREAST, PERFORMED BY MR. JONES AT THE MANCHESTER ROYAL INFIRMARY, FROMJAN. 1ST, 1883, TO DEC. 3l8T, 1892.

524 MR. THOMAS JONES AND MR. JOHN E. PLATT: CANCER OF THE BREAST.

OPERATIONS FOR CARCINOMA OF TUB BREAST, PERFORMED BY MR. JONES AT THE MANCHESTER ROYAL INFIRMARY, FROMJAN. 1ST, 1883, To DEC. 31ST, 1892.—Continued.

525MR. THOMAS JONES AND MR. JOHN E. PLATT: CANCER OF THE BREAST.

LPEttATIONS FOR CARCINOMA OF THE BREAST, PERFORMED BY MR. JONES AT THE MANCHESTER ROYAL INFIRMARY, FROMJAN. 1ST, 1883, To DEC. 31ST, 1892.—Continued.

operation, and the patient died seven months later. Our rule isto remove the entire breast, to dissect off the pectoral fascia, toremove portions of the muscle if necessary, to examine the axillathrough the wound, and if the glands be infected to clear it outcompletely, the breast and the glands, along with the intermediatelymphatic tract, being removed together in one piece. Theassertion is frequently made that the immediate risks to life aregreatly increased by opening the axilla at the time of operation.We contend, however, that the clearing of this space need addlittle, if any, to the risks, provided the proceeding be conductedwith due care, and we would again point out that in 47 of our 55cases the axilla was freely laid open and its contents completelyremoved, and yet there was only 1 death. In some of the casesthe dissection required in order to excise the glands was mostextensive, the axillary vein being frequently exposed for some twoinches of its length. We hold, therefore, that no operation forremoval. of cancer of the breast is complete unless the axilla is

carefully examined through the wound. If the glands be enlarged,be it ever so slightly, their removal is imperative. To leave themis to court defeat, as early recurrence in this situation must beexpected. The only possible objection to the universal adoptionof the rule of examining the axilla through the wound wouldarise from the additional risk involved, and the contention thatthe risk is greatly increased by this procedure falls to the groundn view of the results obtained. There is one practical point in

connexion with this part of the subject to which we wish toinvite attention. It is this: great watchfulness is required onthe part of the anesthetist whilst the axilla is being clearedout; the amount of shock is sometimes considerable, and it iswell not to push the anaesthesia too far at this stage. We havebeen led to dwell at some length on the mode of dealing withthe axilla because one sometimes sees cases in which themammary gland has been successfully removed. but the axillaleft untouched or only imperfectly dealt with ; the diseasehas speedily declared itself in the latter situation and hasadvanced with alarming rapidity, thus bringing the operation intodisrepute.

Of the patients who recovered from the operation 2 havesince died from other diseases without ’recurrence of the cancer,one (Case 27) three months after her discharge from exéessivedrinking, and the other (Case 43) after eight and a half months frombronchitis. Recurrence, including the 4 patients in whom theoperation was incomplete, took place’ in 42 cases, of which 34have since died and 8 are alive. The average duration of lifeafter operation in the 34 cases was nineteen and a halfmonths ; it was under six months in 5, from six to twelvemonths in 10, one to two years in 9, ’two to three years’ in 2three to four years in 6, and four to five years in 2. Of the8 cases now living with recurrence the average time sinceoperation is four years; the longest period in eleven yenra

526 DR. FREDERICK J. SMITH: CIRRHOSIS OF THE LIVER.

and six months and the shortest, two years. The dateof recurrence after the removal of the breast was

doubtful in 8 cases, within three months in 8, three to sixmonths in ’7, six to twelve months in 1, one to two years in 8,two to three years in 3, three to four years in 1, four to five

years in 1, and after ten years in 1. The recurrent growthwas situated in the axilla without recurrence in the cicatrixin 9 cases it affected the cicatrix on the chest wall or its imme-diate vicinity in 19, and the internal organs without localreccurrence in 4 (lungs 2, uterus 1, and subperitoneal glands 1).The opposite breast became affected by carcinoma in a latestage of the disease in 4 of the 38 cases. Operations for theremoval of recurrent growths were undertaken in 11, or just20 per cent. of the total number of cases ; of these, three hadtwo subsequent operations. The rule with regard to recur-rent growths should be to remove them whenever practicableand as soon as possible after they are discovered. The

remaining 6 patients are living and show no signs of return ofthe growth, the time since operation being eleven years, andthree months in two instances, eight years and four months intwo others, seven years in a fifth, and six years in the sixth. Leaving out of consideration those patients who died soonafter the operation, those who have since died from inde-pendent diseases, and those who cannot be traced, 6 casesout of 48 have no recurrence after periods varying from fiveto eleven years. If we adopt Volkmann’s rule that if a

patient is free from recurrence three years after the removalof the growth she is to be considered cured, we can claimthat 12’5 per cent. of our cases were cured by operation.This rule, however, is not always correct, for recurrencesometimes takes place at a very late period ; one of our

cases had recurrence after ten years.From a careful consideration of the foregoing facts we

have drawn the following conclusions :-1. Cancer of the

breast, although a formidable disease, is amenable to treat-ment by operation, and the proportion of cures so obtainedmay confidently be put down at 12 per cent. 2. Non-success after operation is very frequently due to theextensive character of the disease when it first comes underobservation; probably if relief were sought earlier a muchlarger proportion of cures would be obtained. 3. Moderate

enlargement of the axillary glands is no bar to

operation or to a successful issue provided they are

systematically and carefully removed and the axillary spacethoroughly cleared. 4. It is well-nigh impossible to discovertrifling enlargement of the axillary glands by an examina-tion through the unbroken skin. 5. No operation for removalof cancer of the breast can be considered complete unlessthe axilla be examined through the wound, the additionalrisks of such a procedure being very slight. 6. The largenumber of cases in which recurrence occurs locally points tothe necessity of very free removal of the disease ; all doubtfulskin must be taken away and great care must be exercisednot to leave any outlying portions of breast tissue. 7. Opera-tion is contra-indicated when the whole of the growthcannot be removed or when the supra-clavicular glandsare enlarged. The only condition which might renderan operation justifiable under such circumstances wouldbe the presence of a foul cancerous ulcer, the removalof which is desirable on account of the great incon-venience which it occasions.Manchester.

STATUS EPILEPTICUS; REMARKABLENUMBER OF FITS; RECOVERY.BY J. W. ALEXANDER, M.R.C.P.EDIN.,

LATE ASSISTANT MEDICAL OFFICER, LANCASHIRE COUNTY ASYLUM,RAINHILL.

THE following case of epilepsy, in which the patientrecovered after having had an extraordinary number of con-vulsions, may be considered of interest. It occurred in a

woman twenty-six years of age, who was admitted to

Rainhill Asylum on Jan. 4th, 1890, suffering from maniawith epilepsy. From the date of her admission till the endof December, 1894, she had on an average four fits permonth ; one to two days intervened, as a rule, between each,ani at no time were more than five fits recorded in twenty-four hours. After each group of fits she became excited, theexcitement frequently assuming the form of post-epilepticmania of a violent type. Bromide of potassium was taken

by the patient in thirty-grain doses twice daily from themiddle ot May, 1891, till the middle of December, 1894.The series of convulsions which forms the subject of thiscommunication began on Jan. 2nd of this year, a fortnightafter the bromide of potassium was discontinued, and endedtwenty-one days later. The aggregate number of fitsrecorded during these twenty-one days amounted to 3205,the daily total reading as follows:-

The convulsions were almost entirely confined to the rightside of the body, beginning in the arm and spreading rapidlyto the head, face, and leg. The arm was flexed, the legdrawn up, and the head and eyes rotated to the right; occa-sionally the left leg was involved, and more rarely the leftarm also. During the paroxysm urine was passed, but notfaeces, nor was the tongue bitten. Each fit was a distinct

entity, well marked and severe, but of short duration,generally lasting from about thirty to forty seconds, andseparated from that immediately preceding and succeed-ing it by a period of semi or complete consciousness. Therecan be little doubt that the patient’s recovery may beattributed to the fact that these periods existed and weretaken advantage of to give her a sufficiency of nourish-ment. As to treatment, a brisk purge was adminis-tered at the outset, and 111 grains of chloral hydratewere given in the first twenty - four hours, followedduring the second twenty-four hours by 105 grains ofthe same drug. Afterwards ten grains of bromide ofpotassium and ten grains of chloral hydrate were givenevery three hours till Jan. 17th, when the amount of eachdrug was increased to thirty grains every four hours at first,and less frequently as the fits decreased in number and

severity. After the final cessation of the convulsions theright arm and leg remained completely paralysed for a fort-night ; then the paralysis gradually passed off. At this time,the patient’s mental activity having returned, an examinationinto the state of her nervous system was made. She com-plained of great pain in the right shoulder, which was purelydue to passive or active movement; there was no hyper-aesthesia ; sensibility to pain and touch remained unimpaired;the motor speech mechanism was unaffected; ophthalmo-scopic examination revealed no morbid change; there wasslight wasting of the right arm and leg, and the tendonreflexes were brisk, that of the right patella more so thanthe left. Concerning the further course of the illness, theparalysis has now (April, 1895) oompletely disappeared, someslight stiffness of the shoulder alone remains, and no morefits have been recorded.

I am indebted to Dr. Wiglesworth, the medical super-intendent, for permission to publish the case, and toDr. Milne, who was acting as locum-tenens at the beginningof the patient’s illness, for the earlier notes.Armley, Leeds.

CIRRHOSIS OF THE LIVER.BY FREDERICK J. SMITH, M.D. OXON., F.R.C.P. ENG.,

ASSISTANT PHYSICIAN AND SENIOR PATHOLOGIST TO THELONDON HOSPITAL.

IN THE LANCET of Jan. 5th there is published a case byDr. H. B. Donkin which is termed malignant jaundice oracute yellow atrophy. I quite agree with Dr. Donkin thatthe case is rare and interesting enough to be worthy of

publication, but I wish to ask, Was the diagnosis correct?My impression, from a careful study of the report, is thatit was a case of the disease which I believe the late ProfessorCharcot first definitely described-viz., hypertrophic cirrhosis.Before I give the actual reason in my mind for my opinion-viz., an analogous case with microscopical post-mortemexamination-I would like to say something about thefeatures of hepatic cirrhosis in general, if it be onlyto correct what I find is a widespread erroneous view ofthe condition taken by students. For clinical purposescirrhosis may be classified as follows: (1) irregular localcirrhosis due to scarring from healed abscesses, gummata,