DURATION OF THE DISEASE UNTIL DEATH.
As tumors never disappear in a definite manner spontaneously, we can not speak here of a spontaneous course going on to cure. Further, as we possess no therapeutic means which cause a carcinoma to disappear, we cannot speak of a cure in the ordinary sense. Only by operative removal of the tumor can the patient be guarded against the troubles which the tumor itself causes locally, and against the dangers which come from it to the whole organism in one or another form.
In this section I shall only attempt to show clearly how long a woman, who is so unfortunate as to have a cancer of the breast, can expect, under certain conditions, to live. The researches made at different times on this point have, it is true, been based on a definite number of cases, yet it is again very evident, from the difference of the results, how dependent are the results of statistical researches upon the dispositions of the cases, and how the nature of the dispositions are again influenced by the views of different authors. It is now seen that no attention can be paid to the anatomical differences of the forms, because in this respect (even in my clinical journals) there are no sufficiently exact records. Further, the series of observations upon which the comparative percentage calcula tions rest are so unlike, that here also are sources of error. So, for ex ample, the number of observations of " not operated " cases is much smaller, with us at least, than that of the " operated," because the sur geons are less concerned as to the fate of the former than of the latter. If, however, there is some conformity in the results of the statistical re searches of this kind, it is only a proof of such an overwhelming frequency of a certain coarse that the type is expressed even in a few cases. Thus far calculations have been made almost only with regard to the length of time from the beginning of the formation of the tumor until death, and two categories have been made: the " operated" and " not operated " cases. From such series of cases, we have calculated the 'averages.
From this it is seen that there is a great difference between the earlier English and our modern statistics; only Sibley's and v. Winiwarter's figures fix the duration of life of the " not operated " cases pretty exactly; in other respects the figures of the English statistics are considerably higher than ours. Von Winiwarter says: " I explain these differences thus: 1, that the diagnosis in many cases is not certain (in the English statistics); and 2, that I mast leave out all the cured women (by opera tion, and who still live), because I cannot now report on the duration of their life. But now the existence of 21 cases, freed (permanently) of car cinoma, give such an important result to judge from, that the earlier statistics, which only tried to show whether the operation caused an especial lengthening of life, have no further importance for us. But aside from this, I doubt if Paget's and Sibley's calculations, which concern the duration of the life of the patients operated upon, correspond to the reality; I consider them too great in general, if we are to understand that all operated carcinomas of the mamma, without exception, are included in them. I believe that this is partly due to the fact that in England at that
time very different principles prevailed in regard to the operation. If, for example, I so arrange the cases (of operated mammary carcinoma, death from recurrence), that the carcinomas with glandular infiltration before the first Operation are separated from the others, I obtain for the operated cases of cancer of the breast, in which the glands were free, a mean dura tion of life of 50.4 months, while for the remainder there is a mean duration of only 29.2 months. It is evident, since the figure 50.4 corre sponds much closer with the statements of Paget and Sibley (52, 53, 55 months), that at the time in England, a carcinoma with infiltrated glands was never operated upon, but these cases were simply considered as soli me tangere, and were relegated to the inoperable class. But in this way also the average of life's duration for these last becomes much more fav orable, since many of the cases even, with infiltrated glands, live several years." Practically it seems from this that in many cases in which the opera tion is done at a time when the glands are not yet infiltrated, the operation may not only be permanently curable (as will be shown later), but may also prolong life on the appearance of recurrence.
As the mean numbers thus far taken into consideration have no great significance for the individual cases, and none at all for individual groups, von Winiwarter has arranged his cases in still another manner: he has made percentage calculations according to the time of the duration of life from the beginning of the carcinoma until death, and has grouped these by semesters. The following is his resume : "As may be seen, an equally large percentage of operated and non-operated cases die in the fourth half-year, but hitherto about 27.5 per cent. of the former have died and nearly 35 per cent. of the latter. At the end of the fourth year, 11.8 per cent. of the non-operated cases are alive, while 16.6 per cent. of the oper ated are living. The highest mortality of the operated cases falls within the second year; they are those cases in which there is early infection of the lymphatic glands, with recurrence very soon after operation, and which become inoperable early. This group includes according to the above arrangement about 47 per cent, of the whole number of all who die of mammary carcinoma: the remaining 53 per cent. is divided, because the mortality very suddenly diminishes after the second year (from 19 to 5 per cent.) and in later years in gradually decreasing numbers, the re mainder show fluctuations, clearly due to the proportionately less number, and on which therefore I place no great value. If we especially consider the cases which die within the first year after operation (from recurrence) we find that they in no way concern very young women (as one might be led to think from individual impressions). The age of the patients was 44 (in two cases), 50 and 77."