Dr. Maddren: I have tried to do without an anesthetic, and generally ended in making a vaginal examination or resorting to the anesthetic in order to make a diagnosis.

Dr. Gordon: There is very little to be said in closing except to thank the gentlemen who have discussed the paper.

In regard to the treatment of young girls I believe that local treatment should be the last resort. One case I had under observation three years. She married and then I began the electrical treatment. But still I believe that if a young girl is suffering so that she requires opiates, and opiates are the only thing that will give relief, we are justified in using electricity to save her from becoming an opium fiend.

In regard to rectal examinations, I do not know what the experience of others has been, but without an anesthetic I find greater reluctance on the part of the patient, and more disgust from the rectal examination than from the vaginal.

CARCINOMA OF THE BREAST.

BY GEORGE RYERSON FOWLER, M. D.,

Professor of Surgery in the New York Polyclinic, Surgeon to the Methodist Episcopal Hospital, and to the Brooklyn Hospital, Brooklyn, N. Y.

a

A Clinical Lecture delivered at the New York Polyclinic.

The subject of our lecture this morning will be illustrated by woman aged forty-four, who comes to us with the following history: Her family history relating to the occurrence of neoplasms is negative. Her personal history states that she is married, has born five children, all of whom suckled both breasts alike. She has suffered from acute articular rheumatism. She is not sure concerning the occurrence of cracked or fissured nipple in this breast. She had a "broken breast" (acute suppurative mastitis) upon the right side while nursing one of her earlier children. The history obtained from her concerning her present trouble includes a statement that for a number of years she had thought that the breast affected, the right, was somewhat larger than the left, and that two years ago she received a blow upon this same breast. It was within two months of the reception of the blow that she first noticed a tumor of the breast. This has increased rapidly in size until it has assumed its present proportions. More or less pain has accompanied the development of the growth, the pain.

being radiating and stabbing in character.

She has not decreased

markedly in weight, but has lost strength during the past few months.

Inspection.-Examination reveals the following: The breast is half again as large as that of the other side. The nipple is retracted and the skin is thickened so as to present a peculiar goose-flesh appearance. All the structures of the skin of the affected breast

FIG I.-Lines of incision. The dotted line shows the vertical incision occasionally employed.

have undergone hypertrophic changes, and the latter appear to the naked eye very much as the skin of the sound side would appear under a magnifying-glass of low power.

Palpation. The breast is infiltrated to a moderate extent in all its structures. In the upper and outer quadrant there is a distinct. mass, easily distinguished from the remainder of the gland. The breast moves readily upon the chest wall. Beneath the axillary

edge of the pectoralis major muscle several enlarged and infiltrated glands are to be felt. These evidently pass in the direction of the subclavian artery and vein as these cross the space between the chest wall and the pectoralis minor muscle.

The history and appearances of this growth at once stamp it as a case of carcinoma of the breast. The observed varieties of carcinoma in this region are the medullary, the epithelial, the colloid, and the fibrous. The first named is not infrequently observed. The epithelial has its origin in the nipple and is comparatively rare. The most common form is fibrous carcinoma, or scirrhus. It develops between the ages of thirty and forty-five; it has been observed below thirty and in advanced age as well. The predisposing causes are those which relate to the development of carcinoma in general; the exciting causes are believed to be over-lactation, contusions, previous mastitis, and chronic interstitial mastitis. Hereditary influences have been supposed to have a causative relation to the disease; psychic depressions, such as grief and sorrow, are also supposed to have an influence in the popular mind; pregnancy is believed to hasten the progress of the disease.

The location of the tumor in this case is that in which the disease most commonly makes its appearance, namely, in the upper and outer segment of the breast. Glandular lymphatic involvement usually occurs early, although this may not be discoverable until later in the disease. The glands beneath the pectoral muscle are first affected, those of the axilla later on, and those in the infra- and supraclavicular regions last. It has been shown by Heidenhain that there is a free lymphatic connection between the retro-mammary fascia and the pectoralis major muscle, and that infection of this latter structure occurs almost constantly in advanced cases. This may be present also comparatively early in the disease. The nipple appears at first to project, but as the disease advances it becomes retracted or depressed below the surface, owing to the shrinkage of the gland. Fresh foci develop, the individual lymphatic glands, beneath the pectoral muscles and in the axilla, coalesce and form tumors, varying in size, around the large vessels. The arm becomes swollen from venous and lymphatic stasis. Pressure on the brachial plexus produces pain in the arm and paralysis may finally result. In advanced cases the entire soft parts of the chest may become involved, enveloping the bony parts like a cuirass.

The prognosis is always unfavorable if the disease is allowed to pursue its natural course. The average duration of life without

operation is twenty-two months, according to the combined statistics of Winniwarter, Fischer, and Esmarch. Death takes place from ulceration, sepsis, hemorrhage, and exhaustion. The pleura

and, finally, the lung become involved in the disease. Finally, dyscrasial development of the disease occurs, the brain, vertebral column, etc., becoming involved.

The treatment of malignant tumors of the breast consists in

FIG 2.-Breast removed, flaps retracted, and pectoral muscle exposed. total removal of the diseased breast and neighboring lymphatic structures, and other suspiciously affected tissues as well. The condition of pregnancy is not to be considered a contraindication to operation. The existence of lymphatic involvement may not be demonstrable until after exposure of the parts by turning back a flap of skin. It is not enough to simply enucleate the individual glands; the entire fatty and lymphatic glandular contents of

the axillary cavity, the loose connective tissue between the latissimus dorsi and pectoralis major muscles, the glands and connective tissue beneath the latter muscle and passing from it to the breast, and, save in exceptionally early cases, the pectoralis major muscle itself, must all be removed. If necessary the pectoralis. minor muscle as well, must be completely extirpated. Should the supra- and intraclavicular glandular structures be involved, these must be removed as well.

Some surgeons prefer to commence the operation by removal of the lymphatic glandular structures involved, in order to prevent dissemination of the disease by the necessary manipulations in removing the breast, while others enucleate the subpectoral and axillary glands, sever their connections in these localities, and remove the mass, together with the breasts and pectoralis major muscle as the last stage of the operation (Halstead). The difficulties attending this method, however, are great, and it is my habit in suitable cases, to remove the breast first. Considerable time is thus saved. In those advanced cases in which well-marked cancerous tissue, attaching the breast to the underlying muscular structure, is present, and in which the fear of spreading infection seems to contraindicate cutting through this, the attempt to avoid this by removing the breast, muscle, and fat and glandular structures in one mass consumes from one to three hours. By the method which I shall employ in the case before us an average operator can do the entire work in from twenty-five to thirty-five minutes with ease.

When the subclavian artery and vein pass through the glandular growths, the involved portions of the vessels have been extirpated between two ligatures. The conditions under these circumstances, however, are usually such as to preclude the removal of the entire disease, and there is a growing belief among surgeons that such growths should not be attacked. Glandular involvement in the supraclavicular region also renders the prognosis very unfavorable.

The skin incisions must be planned so as to go wide of the diseased breasts, and so placed as to afford easy access to the entire mammary region, and, by extension, to the axillary, infraclavicular, and subpectoral regions as well. In making the deeper dissections the blood-supply should be taken into account, and the vessels which supply the gland divided and clamped early, in order to avoid constant repetition of this part of the technic. Bleeding points must be secured at once, and if the clamp-forceps