EXTIRPATION OF THE MAMMA AND OF THE AXILLARY GLANDS.
-In the history of e,ancer of the breast, we can study the different views as to the nature and treatment of cancer in general. Whoever is especially interested in the subject can find the material in the history of surgery by K. Sprengel, collected with great care, but with little criticism. Only a small portion of it can be in troduced here.
Hippocrates mentions the great frequency of scirrhus in the female breast, but Galen was the first to give an exact description of the nature of extirpation of the breast, and recommended that this be done with the knife. Later, hot irons were used for this purpose, alone or with the knife. The views as to the advisability of the operation varied a great deal. The capability of scirrhus for recurrence was perfectly known in ancient times. But the differentiation of swellings of the breast did not go beyond the conception of cancer occultus and aper tus. It was much later in the middle ages that abscesses were differen tiated as apostemata; and then was defined the difference between scir rhus, cancer and struma of the mamma, although these were very much mixed. Caustics came into more frequent use in the middle ages, partly as popular remedies; sublimate or arsenic was generally used. Nor has there been any lack of recommendations of specifics against cancer from the middle ages to the present time, and almost all active therapeutic remedies have played parts as specific cancer cures. Arsenic, mercury, iron, and then hemlock and belladonna, were especially used internally.
Most observing surgeons soon saw, however, the inactivity of internal measures, as well as the danger of insufficient caustic measures and other severe dressings. The recommendation to extirpate the concealed cancer, and to treat the open incurable cancer mildly, is very old. The best sur geons have always spoken in favor of the early operation for scirrhus; but if there have been accounts of frequent complete cures, it is very prob able that they refer to the benign, hard feeling tumors, as every tumor which felt hard was formerly called scirrhus. A more exact differenti
ation of tumors of the breast, based on more painstaking observation of patients, and on anatomical examination of the tumors was first begun by Abernethy and Astley Cooper, those heroes of English surgery at the be ginning of this century.
In the middle ages the whole breast was almost always amputated; later came the recommendation to incise the skin and extirpate the tumors, if they were small. The removal of the whole breast, with the greatest possible preservation of the skin, first came into vogue in the last century.
Formerly the whole breast was raised, and cut off as quickly as possible close to the thorax with a large amputating knife. In behalf of. more rapid and easier removal by this elevation of the breast, almost all modi fications of the method of operating are made. Joh. van Horne drew stout threads crosswise through the breast in order to make it more tense; Corn. van Solingen used a large fork for the purpose; Adrian Helvetius used a forceps with double hook attachment for this purpose (from which the now so-called Muzeux's forceps probably originated); and H. Vylhorn invented a large cutting forceps fir removing the breast quickly.
Fabricius von Aquapendente and Fabry von Hilden were the first to remove the affected axillary glands, and for this purpose the finger was recommended as the best means, after the incision of the skin; a proce dure which was more systematically perfected by J. L Petit.
Extirpation of the breast is total or partial, and is scarcely ever done except for tumors. Partial extirpation is especially done for benign tumors of the breast, where the tumor is dissected out of the gland, and the rest of the latter allowed to remain. In carcinoma, it is better in most cases to remove the whole gland, though, from my experience, I cannot prove statistically that recurrence is more rapid after partial ex tirpation of smaller cancerous tumors with removal of a proper amount of the surrounding healthy glandular tissue, than after total extirpation of the gland.