Cl)c Boston Sectoral anti Jnirgiral journal 
'"WWhumted fromj 
APRIL ii. 1889. 
THE DIAGNOSIS AND TREATMENT 
OF 
CANCER OF THE BREAST 
BY 
J. COLLINS WARREN, M.D., 
Associate Professor of Surgery in Harvard University, Surgeon 
to Massachusetts General Hospital. 
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2£o£tou. THE DIAGNOSIS AND TREATMENT OF 
CANCER OF THE BREAST.1 
J. COLLINS WARREN, M.D., 
Associate Professor of Surgery in Harvard University, Surgeon to 
Massachusetts General Hospital. 
The great changes which have recently taken 
place in the treatment of this formidable disease 
have invested it with a new interest, and it has there- 
fore seemed to me that the subject of this paper 
was as appropriate a one as could be presented to 
your society by the general surgeon. Until within 
the present decade the success which has attended 
operative interference has been so unsatisfactory 
that many surgeons, among whom I should count 
myself, had become discouraged, and had chiefly 
confined themselves to operations upon exception- 
ally favorable cases, or to those which demanded 
operative interference for the relief of suffering 
merely. 
The old method of operating contemplated either 
a removal of the mammary gland with a portion of 
the integument, or even of a portion only of the 
gland and other tissues immediately surrounding 
the disease. When enlarged glands were felt in the 
axilla an incision was prolonged from the wound 
a short distance beyond the border of the pectoralis 
muscle, and the glands were shelled out with the 
finger or some blunt instrument. It was in rare 
instances only that more radical operations were 
attempted. The bold methods advocated by Mitchell, 
Banks, Keuster, Gross and others are now in course 
of adoption by the surgical world, and a new mass 
1 Read before the Boston Gynecological Society, February 14, 
1889. of statistics is gradually being accumulated which is 
rapidly furnishing material for reopening the study 
of this question. 
It is important to lay some stress upon the kind 
of material that should be used for this purpose, 
for recent discussion has brought out very decided 
opinions from men whose views should be regarded 
with the greatest respect, but who are not disposed 
to look upon the so-called “ completed operation ” 
as an advance upon the older methods. 
There are good grounds for rejecting the great 
mass of statistics which have been compiled pre- 
vious to the present decade. 
In the first place, microscopic examinations are 
wanting in the majority of cases, and many of those 
which have found their way into reports of cases 
have not been reliable. Not only have some cases 
reported as carcinoma proved on further study to 
belong to non-malignant growths, but there are 
also types of disease regarded as forms of inflam- 
matory affections of this organ in which the expe- 
rienced pathologist is able to detect early changes 
in the growth of the epithelial structures, which are 
the first steps in the development of a carcinoma. 
Again, although the antiseptic treatment of 
wounds was first introduced nearly a generation 
ago, it is only within a few years that the system 
has become so generally perfected that the average 
surgeon has been able to arrive at the results con- 
templated by its author. Each succeeding year 
brings with it a material improvement in mortality 
statistics, and it would be manifestly unjust to esti- 
mate the amount of danger and suffering entailed 
upon a patient subjected to the operation from 
material which has been collected previous to the 
last few years. 
The advocates of the completed operations are 
now laboring under the same difficulties in edu- 3 
eating the surgical public up to their standard 
of operation, precise rules for which are rigorously 
laid down, and which should be closely adhered to 
by those attempting to give the new method a 
proper test. When these conditions shall have be- 
come so familiar to all surgeons that cancer will be 
recognized during the earliest periods of existence, 
that the diagnosis will be promptly followed by 
an operation, that the operation will be so thorough 
in character that it will come up to the most exact- 
ing standard, and that the patient may reasonably 
expect the full benefits of the antiseptic system, 
there will, I think, be but little doubt that the very 
unfavorable prognosis now generally accorded to 
this disease will have to be materially modified. 
Let us consider first what may be done in the way 
of an early diagnosis. 
When a woman of middle age presents herself 
with an indurated mass in the mammary gland, 
which has already involved the skin, and there exists 
at the same time a retraction of the nipple, and 
possibly a slight fulness of the axilla of the same 
side, the diagnosis is so clear that a tyro would find 
it hard to make a mistake. The problem, however, 
is far more difficult, and often embarrassing, when 
an anxious woman has only an indurated spot in 
the breast to show, and expects the surgical expert 
to give a definite opinion. There are a few facts 
bearing upon the etiology of this disease which it 
is well to bear in mind in making up an opinion. 
Among the most important of these is the age of 
the patient: according to Gross2 “the largest number 
in 1622 cases in which the age of the patient was 
noted was found to be between forty and fifty years, 
the next largest number was found between fifty 
and sixty years, the next in the thirties, and the 
next in the sixties. The earliest age at which can- 
2 American Journal Medical Sciences, April, 1888. 4 
cer of the breast was reported is given by Henry 
as twenty-one. Very few cases are seen before the 
age of twenty-five. A case under my care at pres- 
ent in the hospital is that of a girl of twenty-two, 
and owing to its rarity deserves record here. 
Lizzie M., twenty-two years six months old. Horn in Boston. No 
cancer in her family, so far as known. Previous history good, un- 
married. Catamenia regular. Presented herself at the Massachu- 
setts Hospital, January 25, 1889. Three months before noticed a 
lump in the left breast, and almost at the same time a gland in the 
axilla. She is well developed and nourished. In the upper and outer 
quadrant of the left breast there is an indurated mass the size of an 
English walnut. There is no involvement of the skin, but a slight 
dimpling exists. No retraction of nipple. There are some enlarged 
glands above the clavicle, but these are said to have existed for a long 
time previous to any breast-disease. 
The completed operation was performed January 26th. The 
glands did not extend upward beyond the lower margin of the pecto- 
ralis minor. There was considerable shock, that night the tempera- 
ture falling to 95.8°. Pulse, 120; respiration, 48. Prompt reaction took 
place, however, and the convalescence has been rapid and without 
further complications. Suppuration around one suture and opening of 
the wound at that point: otherwise union by first intention. Micro- 
scopic examination of tumor by Dr. Whitney. “ A dense, somewhat 
translucent, retracting nodule deep in the breast. A section pre- 
sented a whitish, fibrous-looking surface, with mucous, small opaque 
yellow dots and lines. Microscopic examination showed it to be made 
up of a thick, dense, small-meshed, connective-tissue groundwork, in 
the spaces of which wrere solid masses of rather small, cubical, epithe- 
lial cells, many of which were fatty degenerated. Scirrhus cancer. 
Another sign of value is the locality of the tumor, 
if we may accept again the testimony of Gross. In 
820 cases, the disease was found in the upper and 
outer quadrant in 206, near the nipple in 235, and 
in the upper hemisphere twice as often as in the 
lower hemisphere. Speaking from general impres- 
sion only, I should he inclined to agree with the 
deductions made from these figures, namely, that 
we are more likely to find the disease in the upper 
portion of the gland, and more likely also to find it 
nearer the axillary than the sternal margin of the 
gland. 
The influence of heredity has often been quoted 
as a characteristic peculiarity of cancer. Sir James 
Paget has cited a number of remarkable instances 
of the disease occurring among relatives. An ex- 5 
ample of this tendency was afforded by one of my 
own cases. Her maternal grandmother died of can- 
cer of both breasts, at the age of thirty. A maternal 
aunt died of cancer of the breast. A cousin on her 
mother’s side died of cancer of the rectum. An 
aunt on the father’s side was operated upon recently 
at the Massachusetts General Hospital for a cancer 
of the breast. But Gross found a family history 
of cancer in only 8.50 per cent, of his cases. 
An undoubted record of the prevalence of cancer 
in a family would, I think, have considerable weight 
in enabling one to make a diagnosis in a doubtful 
case. The difficulty in obtaining a record which 
would approach in accuracy the standard now de- 
manded as evidence of the existence of cancer would 
be almost an insuperable obstacle. The informa- 
tion ordinarily to be obtained from a patient bearing 
upon this point is practically of little value. 
A slight dimpling of the skin is thought by 
Gross to be a sign of considerable importance, as 
one which is to be found at an early stage of the 
disease. This is due to a pulling upon the fibrous 
bands which attach the skin to the mammary gland, 
by the contraction of the diseased portion. I have 
seen this depression in cases in which I made the 
diagnosis of chronic mastitis, and thete seems to me 
to be no ground for assuming that an inflammatory 
condition of the mammary tissue in a state of invo- 
lution should not give rise to such an appearance. 
In fact, we may have all the external appearances of 
cancer of this organ simulated by inflammation. A 
striking illustration of this fact was observed by me 
in the breast of the wife of a brother practitioner. In 
this case there existed, in addition to an indurated 
nodule in the outer hemisphere of the breast, a re- 
traction of the nipple and an enlargement of the 
axillary glands. The nodule proved, however, to 
be inflammatory, and disappeared entirely a few months afterwards ; and the patient at the present 
time, several years after the disappearance of the 
swelling, is in excellent health. Retraction of the 
nipple is indeed often a misleading symptom; for 
it is not infrequently found in breasts that are 
entirely healthy. 
. Many of the cases submitted to the surgical spe- 
cialist are therefore, as I have said, extremely dif- 
ficult to diagnosticate in the early stages of the 
disease; and yet this is the period which is gener- 
ally recognized as the one in which diagnosis is of 
great value. A striking example of the difficulties 
which attend such a case is afforded by a patient 
sent to me in March, 1888, by I)r. Brown, of Read- 
ing, Mass. 
Mrs. P., forty-five years of age, received a blow from a sharp ob- 
ject eight weeks before. The blow was immediately followed by a 
swelling below the nipple, at the point of injury. In a few weeks the 
swelling had diminished Somewhat, but a small indurated mass was 
still to be felt at that point. There was no dimpling of the skin, and 
no enlargement of the glands in the axilla. The patient’s general 
health was good. The growth appeared to be of an inflammatory 
nature. I advised her to let me see it again in a few weeks. She 
visited me a second time, on May 19th, and the breast was then found 
to be entirely infiltrated with cancerous disease, presenting a hard, 
brawny mass; the glands in the axilla were also considerably en- 
larged. I then, of course, recognized a very malignant type of can- 
cer, and advised no operative interference. She received similar 
advice from several other surgeons, but eventually had it drawn out 
“ by caustic; ” and Dr. Brown informs me that she died December 
11th. 
It is probable that operative interference at 
any period would not be attended with satisfactory 
results in such a malignant type of the disease, but 
it would certainly be more creditable to surgery 
were it possible to give a definite diagnosis in doubt- 
ful cases, for it is in precisely such a class of cases 
that the surgeon is most likely to be consulted. 7 
Aii old method of ascertaining 
the nature of morbid growths con- 
sisted in the introduction of a 
grooved needle into the tumor, 
and submitting to microscopic ex- 
amination such fragments or 
juices as could be extracted. Quite 
a variety of instruments were de- 
vised for this purpose, but owing 
to the danger of producing in- 
flammation by such a manoeuvre, 
unprotected by antiseptic meth- 
ods, and to the imperfect micros- 
copic technic, which consisted 
principally in poking the frag- 
ments apart with needles, no 
satisfactory results were obtained, 
and the method gradually fell into 
disuse. 
It occurred to me about a year 
ago that this plan might be re- 
vived under the favorable auspices 
of antisepsis, and perfected by 
the improved microscopical meth- 
ods. An instrument devised by 
Dr. S. J. Mixter for removing 
grains of powder from the skin 
was suggested by him as suitable 
for the purpose. It consists in a 
fine eanula (No. 6 Charriere filiere), 
sharpened on the inner edge, 
which, when rotated by means of a handle 
at its upper end, acts like a trephine to 
remove a minute circular disk of skin. I 
have had a number of different sizes made, gradually 
enlarging them as experiment showed the absence 
of unfavorable results attending their use, until I 
have reached as high as Charriere’s No. 12. This 8 
gives a diameter of about 4 mm., — a size suffi- 
ciently large to take a section of ample dimensions 
for microscopic study, even from a transverse sec- 
tion of the fragment removed. A small staff is 
kept within the canula to protect the cutting edge 
when not in use, and to remove the specimen from 
the canula. 
The method of making an examination with this 
little instrument is so simple that it can be easily 
carried out in one’s office. A few drops (about ten) 
of a five per cent, solution of cocaine is injected 
subcutaneously over the nodule to be examined. 
The skin, having been carefully cleansed with a 
weak solution of bichloride of mercury, is punctured 
with a sharp-pointed bistoury, making a minute 
wound, sufficiently large to introduce the exploring 
canula. The instrument is then pressed gently 
against the new growth, and lightly rotated between 
the thumb and middle finger. As little pressure 
should be exerted as possible. After the canula has 
penetrated the growth the desired distance, from half 
an inch to two inches, it should be withdrawn a dis- 
tance of two or three mm., and then directed in a 
line slightly oblique to the direction which it had 
first taken. By rotating now a short distance in the 
new direction, the cylindrical mass of tissue con- 
tained within the canula will be divided, and can be 
removed from the diseased mass. The worm-like 
mass of tissue pressed out from the canula by its 
staff should be immediately placed in a weak solu- 
tion of alcohol, which gives place the following day 
to strong alcohol; or it can be placed upon the 
freezing microtome, and longitudinal sections be 
taken for immediate study. 
When the canula is carefully introduced, a seg- 
ment of the tumor can be obtained showing the va- 
rious appearances from the extreme periphery to the 
central portions, so that there is no danger of ob- 9 
taining a false impression owing to a partial 
examination only of the growth. 
In one of the first cases in which I employed this 
method the growth proved to be a chronic mastitis, 
with cystic degeneration. The section showed 
clearly the interstitial fibrous tissue, with acini and 
ducts of the glands supported in it. In this case 
there was great mental depression and nervousness, 
which by a definite diagnosis it wras possible to 
relieve. 
The following is a sample case, showing what 
may be accomplished by the method: — 
Miss C., fifty years of age, always healthy, has had for several years 
a small lump near the axillary margin of the left breast. Six months 
previously, had noticed a slight enlargement, since when it has been 
under the observation of her physician. As it did not disappear, she was 
sent to me. I used the finest canula (No. 6), and sent the specimen 
to Dr. Whitney for examination. An examination of a fragment in 
the fresh state showed clumps of epithelial cells floating in some of 
the fluid serum removed, and the diagnosis of cancer was made, which 
was confirmed after removal of the breast. 
When the larger canulae are used, the alveolar 
structure can easily be demonstrated. 
In the case just mentioned the little wound made 
by the knife was covered with antiseptic cotton, and 
sealed with collodion, and at the time of the next 
visit of the patient the wound was found to have 
healed by first intention. Prompt healing of the 
wound has always been the result in those cases 
hitherto examined in this way, and the patients 
have complained of no particular pain or inflamma- 
tion as the result of the operation. In one case a 
small artery was wounded; but union took place 
promptly afterwards. The boring of the canula 
through the dense morbid tissue might be supposed 
to cause some pain; but this is avoided by the 
gentle rotary motion of the instrument. I have 
succeeded in making a diagnosis in a large variety 
of morbid growths explored in this way, in doubtful 
cases. 10 
There is a certain ty]ie of this disease in which 
an early diagnosis is of special advantage, as an 
operation at this period affords a favorable prospect 
for a radical cure. I refer to those cases where the 
disease appears to supervene upon a chronic inflam- 
matory process, and the mass can be removed while 
the cancerous degeneration is still limited to the 
inflamed nodule. Such a case is the following : — 
Miss W„ fifty years of age, sent to me by Dr. F. I. Knight, had 
noticed an indurated lump in the upper hemisphere of the right 
breast, six months previously. It had not increased in size since that 
time. No glands were felt in the axilla. I advised an operation’with- 
out previous exploration. On laying open the breast, the appearances 
were so suggestive of a chronic mastitis that I thought I had made an 
incorrect diagnosis, and did not open the axilla. 
The following is the report made by Dr. Whitney of the microscopic 
examination: — 
“ The whole gland is replaced by a dense white tissue, in which 
were several cavities, the largest as big as a robin’s earg. These were 
lined with a smooth membrane, and had evidently contained fluid. On 
microscopic examination, the basis of the growth was found to be 
composed of a dense fibrous tissue. In this were embedded the 
altered glandular elements. In places, the ducts were dilated, evi- 
dently the origin of the large cysts seen in the gross. Here and there 
the acini of the gland were reduced in size, and the cells smaller, as 
if undergoing atrophy. In other places the cells had proliferated and 
extended widely from their original place in a plexiform network into 
the surrounding tissue. In places these lines of cells appeared to fol- 
low the course of the lymphatics. Here and there a compound gran- 
ular cell was seen, but in general comparatively liftie fatty degenera- 
tion. The growth seems to be a diffuse, interstitial fibroma, in which 
the gland elements are now beginning to proliferate actively. Com- 
mencing cancer.” 
Although no dissection of the axilla was made in this case, I have 
expressed a very favorable prognosis, as it seems to me that the very 
early stage of development of a cancer precludes the possibility of 
infection beyond the point of inflammation. 
And this brings me to another branch of our sub- 
ject, namely, the question of the local origin of the 
disease. 
There are some very high authorities in favor of 
the view that, although not necessarily a blood dis- 
ease, it is not, on the other hand, purely of local 
origin. Such is, I think, the inference to be drawn 
from the attitude assumed by Dr. Ii. M. Hodges in 
his recent paper upon excision of the breast,3 
which has, I need not say, excited much interest. 
3 Boston Medical and Sureical Journal. Nov. 29, 1888. 
* New York Medical Journal, Oct. 13, 1888. 11 
Sir James Paget says: “ Once formed, the secondary 
diseases and much of all that follows, even to the 
inevitable end, may be due to transference of can- 
cerous materials from the primary growths. But 
I do not think that all the secondary and yet later 
events can thus be explained. We have no reason 
for believing that the morbid material of the blood 
is always exhausted in the formation of the primary 
cancer, and it seems more probable that in some 
form this material remains or is renewed, and that 
to this, as well as to transference from the primary 
disease, the secondary and later changes are to be 
ascribed.” 
There are many cases which give grounds for 
such a belief. Thus, cases reported by Ur. Gouley4 
of excision of the breast for scirrhus cancer, with 
recurrence twenty, twenty-four, and twenty-five 
years after operation, are suggestive of more than 
purely local influences. But without attempting to 
offer elaborate evidence 'pro or con bearing upon 
this question, I must enroll myself with those who 
believe in the purely local origin of cancer. 
The habitual progress of the disease from one 
anatomical structure to another; the steadily di- 
minishing size of the cancerous deposits as we 
proceed from the periphery towards the centre of 
the lymphatic system; the analogy between the 
manifestations of this and other forms of disease 
whose local origin is well recognized, — are all so 
strongly suggestive of a local origin, that it is diffi- 
cult in the light of modern pathology to accept any 
other interpretation. 
It seems to me, therefore, that with the benefits 
accruing from the opportunity to make an early and 
certain diagnosis, if we undertake to remove, not only 
the tangible evidences of disease, but all those 
structures which experience shows are habitually 12 
involved at a comparatively early date, we have a 
right to hope for more satisfactory results than 
have hitherto been obtained. 
Let us have a mutual understanding as to the 
essentials of the so-called completed operation. 
Surgeons differ somewhat as to the amount of breast 
integument that should be removed. The followers 
of Gross, who makes a circular sweep of the whole 
breast, are comparatively few, and even he now 
proposes to abandon it in cases which he can keep 
under observation, and thus be enabled to remove 
promptly recurrent nodules. Butlin, whose work 
on the operative treatment of malignant disease 
has attracted so much attention lately, does not 
think it necessary even to remove all of the mam- 
mary gland, although he does attach importance 
to the inclusion of a wider margin of integuments 
than the old operations contemplated. It is gener- 
ally agreed at present, I think, to remove the whole 
gland and a more liberal supply of integument than 
formerly. Sometimes vertical incisions are preferred 
to the customary horizontal cuts, as affording better 
drainage. But the most important feature of this 
part of the new operation is the careful dissection 
of the fascia from the pectoral muscle, for it is in 
this tissue that capillary lymphatics are concealed, 
which furnish hiding-places for the outposts of the 
disease. Careful attention should also be paid to 
the margin of the pectoral muscle : not only should 
the fascia which covers in the axilla be dissected off 
from it, biit its lower border should be well freed 
from fat and connective tissue. The axilla is best 
opened by a cut through the skin along the edge of 
the pectoralis, until we come to the edge of the 
coraco-brachialis. Continuing down on this muscle 
a short distance with the knife, the skin and 
superficial fat drop away sufficiently to disclose the 
great vessels lying beneath a thin fascia. Opening 13 
this fascia backward along the line we have come 
exposes the contents of the axilla, and especially 
the branches of the vessels, which can now be se- 
cured as the operation progresses. A pyramidal 
mass of fat is now dissected out, the apex reaching 
sometimes to the clavicle, the base frequently ex- 
tending deeply on to the subscapular group of mus- 
cles. The glands which lie near the clavicle will 
have to be removed separately, and can best be 
enucleated from the neighborhood of the vessels by 
the linger. If they are numerous, the pectoralis 
can be separated on the line selected for the ligature 
of the axillary artery below the clavicle, and the 
glands and some of the loose tissue can then be 
readily removed. This plan I recently employed 
in the case of. a lady fifty years of age. The wound 
healed without complications, and the patient 
made a rapid convalescence. 
This operation is doubtless far more severe than 
any of the old methods; but under careful antisep- 
tic precautions, which are constantly being improved, 
I cannot help feeling that the mortality rate is 
now on a descending curve. Dr. M. H. Richard- 
son,5 in his paper on the results of this operation, 
is inclined to think that the mortality is increased 
50 per cent, by the new method. This impression 
was obtained, I think, from a study of some of the 
earlier series of the “ completed operations.’’ It is 
also Butlin’s opinion. As the increased mortality 
rate has been used as an argument against the com- 
pleted operations, I have taken pains to look up the 
results of my own operations within the last few 
years, and find that, in forty-seven consecutive 
cases of excision of the breast, there have been no 
deaths. In thirty-two cases only of these was there 
a dissection of the axilla. The duration of conva- 
lescence is much shortened, and complications are 
s Boston Medical and Surgical Journal, August 30, 1888. 14 
rare. Shock is a complication to be guarded against 
always, but in comparatively few cases has this been 
of sufficient gravity to cause alarm. I am inclined 
to think powerful antiseptic drugs have been re- 
sponsible for more than one case of fatal poisoning 
before the proper limit of their use was generally 
understood. 
A more minute knowledge of the actual course of 
the disease through the lymphatic vessels, which 
ramify along the border of the pectoralis and in the 
axillary region, may enable us to curtail materially 
the present wide range of dissection. Here is a 
held for future research. 
Sir Spencer Wells 6 has shown, from Dr. Creigh- 
ton’s observations, that tumors of the sweat glands 
of the axilla may form nodules on the axillary mar- 
gin of the breast and in the axilla. In these cases 
the disease has no connection necessarily with the 
mammary gland, and the breast need not be removed. 
The study of the pathology of this region, in spite 
of many valuable works, cannot as yet be considered 
as exhausted. 
In 605 cases collected by Butlin, the mortality 
Avas 15.85 per cent., or 1 in 6. Cheyne reports 37 
of Lister’s cases, with 2 deaths. In 24 of these 
cases the axilla was dissected. In Butlin’s 40 cases 
there were 3 deaths. Butlin thinks that the mor- 
tality of the completed operation is twice as great 
as that when the breast alone is removed. Gross 
makes out a mortality of 14.24 per cent, for all 
kinds of operations. In 43 completed operations 
performed by himself, there were only 2 deaths; 
1 from fat embolism, and 1 from pneumonia. In 
10 additional operations by his colleagues, recovery 
took place in every instance. The mortality in this 
series was therefore only 3.7 per cent. 
fc Morton Lecture on Cancer and Cancerous Diseases. London : J. 
& A. Churchill, 1888. 15 
In regard to the number of cures effected by opera- 
tive treatment, the percentage figures seem discour- 
agingly small; but when we remember that in old 
times a case of permanent cure was regarded as a 
surgical curiosity, it must be acknowledged, I think, 
that a tangible improvement has taken place. 
Gross obtained from his collections a percentage of 
11.83, when the patient was alive and well three 
years after operation. As in only 2 per cent, of 
cases did recurrence take place after three years of 
immunity, this limit has been accepted as an indi- 
cation of cure. Butlin thinks the percentage of 
cures should be placed as high as 12 to 15 per cent, 
at the present time. 
In those cases in which a fatal termination was 
reached before the three years’ limit, Gross found 
that there was an average prolongation of life of 
ten months when the axilla had been dissected. 
I regret to say that I have not had an opportu- 
nity to ascertain the histories of all the cases of my 
series. I have, however, been able to follow the 
history of several mentioned in a former paper,7 
and will briefly refer to them here. 
Three years and a half immunity. Mrs. II., Amesburv, Mass., about 
sixty years of age. Disease had existed two months' A hard and 
voluminous cancer of the breast, with large glands in the axilla ex- 
tending as high as the clavicle. The completed operation was per- 
formed. The case was not a promising one, and in former times 1 
should have declined to operate. The operation was performed July 
9,1885. Dr. H. G. Leslie writes me, under date of January 14,1889: 
“ I have to report that Mrs. B. still remains in perfect health, with no 
signs of the recurrence of the disease.” 
Four years’ immunity. Miss B., about forty years of age, was oper- 
ated upon in December, 1884. First noticed a tumor in the breast the 
nrevious winter : but an eczema of the nipple had existed in 1883. 
Iso glands were felt in the axilla ; but the completed operation was 
nevertheless performed, with the result of finding one small nodule 
in the axilla. She was married October 15, 1888, after an engage- 
ment of seven years’ standing, no sign of a recurrence having shown 
itself, and her health having greatly improved. 
Four years and a half immunity. Miss J., Haverhill, Mass., was 
operated upon in June, 1884. The breast was very voluminous and 
the cancerous nodule was small, and situated near the sternal margin. 
The axilla was opened, but no glands found. Dr. M. D. Clarke writes 
?Boston Medical and Surgical Journal, February 17, 1887. me, under date of January 30th, 1889, that he has recently visited 
Miss J., and that there has'been no return of the disease. 
Five, anda half years' immunity — recurrence. Grace M., forty-five 
years ot age, was operated upon in the hospital, in July, 1882. There 
wasno gland in the axilla. Had firstnoticedalumpthree years before \ 
no return of the disease until the autumn of 1887. A lump was then 
felt in the axilla. 
A nodule the size of a hen’s egg was removed from the axilla 
in July, 1888. It was found to be a colloid cancer. There was 
no return in the breast. At the present date both breast and 
axilla are free from disease; but the patient’s general health is not 
good, and I fear a development of the disease internally. I cannot 
help feeling that, had the completed operation been performed in 
this case, there would have been no recurrence. 
Ten years' immunity. M. E. M., thirty years old. Disease four years’ 
duration. An ill-dehned tumor of the right breast, the size of an egg. 
Operation performed September 18, 1878. The tumor, on section, 
was found to be very dense, and intiltrating nearly the whole breast. 
The breast was excised, but the axilla was not opened. The patient 
was living in January, 1888, and there had been no return of the 
disease. This case is taken from the record book of the hospital; and, 
as no microscopic examination was made, and I have no recollection 
of the case, the diagnosis may be considered doubtful. 
If we add to Gross’s 53 cases of completed opera- 
tions my own 32 cases, we have a series of 85 cases 
with only two deaths. 
It seems fair to assume, therefore, that a mortal- 
ity rate of 3 per cent, is not too much to hope for in 
the future. 
If Butlin, whose operations are much less radical 
than those of Gross, thinks that cures are obtained 
at the present time in 15 per cent, of the cases 
operated upon, may we not hope for a still further 
increase of this percentage if a ready method of 
diagnosis enables us to operate in the earlier stages 
of the disease ? 
I do not think it is too much to expect that, when 
the statistics of the next few years are rolled up 
and counted, we shall find that surgery has suc- 
ceeded in accomplishing a cure in 20 per cent, of 
the cases. 
I am well aware that many interesting points of 
this snbject have not been touched upon, but the 
intended scope of this paper will hardly authorize 
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