RECURRENT AFFECTIONS AND FINAL CURE IN CANCER OF THE BREAST.
It is not yet half a century since we have been freed from the dogma: "all recurrent tumors are cancers." First we began to differentiate be tween the multiple appearance of tumors in the territory of one and the same system of tissue, and between the multiplication of a tumor by a seed spread by it throughout the body. Then followed the division of the latter group into several classes. A strict limitation of this first re sulted from a careful classification of recurrent and infectious tumors, as was especially done by Thiersch. At present we are accustomed to differ entiate: 1. Continuous Recurrences at the Site of Operation.—These always arise from portions of the tumor left behind at the time of operation, either because they could not be removed on anatomical grounds, or be cause they were overlooked. They are thus always the result of an in complete operation or of one that cannot be completed. There is then always a fault with the operator, if we may designate the incompleteness of our store of knowledge as such. Operators have long hesitated to ac knowledge this. These continual recurrences occur shortly after opera tion, sometimes even before the wound is healed, because we usually allow the wound to heal by granulation, which, in extensive operations, may require three months or longer. It is seldom that foci, left in the mamma, remain quiescent and first begin to grow after a long time has elapsed. Both the patient and surgeon are soon aware of these, by far the most frequent kind of recurrences after extirpation of the mamma and axillary glands.
2. Regional Recurrences.—After a longer time, sometimes even after twenty years, a recurrence will appear at the cicatrix of the operation.
This is the case almost only in sarcoma, and is certainly very rare in car cinoma. We can hardly imagine, that, in such cases, the smallest mi croscopic foci, which have been left at the time of operation, have remained quiet for so long a time without vowing, and we therefore oonclude that new tumors have arisen at the site of operation from the same (un known) causes, which originated the first tumor. Regional recurrences are thus entirely new tumors springing up independently of the first tumor.
3. Infection Recurrenres.—We amputate a mamma containing a car cinoma and leave the axillary glands because they absolutely cannot be felt; a few weeks or months after the healing of the wound, a carcinoma appears in the axillary glands, perhaps without the simultaneous forma tion of a regional recurrence, and even without such a recurrence devel oping at all. In regard to this, the older humoral pathologists reflected as follows: The carcinomatous juices in the body have discharged into the breast, and there concentrated; we have removed the product of its action, the cancerous tumor, which continually draws the carcinomatous material from the blood to itself and consumes it; now the peccant ma terial settles in the lymphatic glands and here forms new products. Conclusion: cancer should be allowed to remain, as it attracts all the juices to itself, as long as possible, though it gradually undermines the strength of the organism by its ulceration. If it was removed, it was thought that at least the blood would be freed from the peccant material by the cure or else it would continually reappear here and there. This view, which is rapidly disappearing from the minds of physicians, has an uncommonly strong hold upon the public, so that the craze of carcinoma patients for " blood cures" is still very great.
Modern pathology takes a very different view of the matter. If car cinoma has been thoroughly removed, so that no continuous recurrences appear, and yet carcinoma appears in the glands, we now generally take the view that particles of the primary tumor had already entered the glands before operation, which we did not know, because we could not recognize them (again a very unwilling and very gradually conceded incompleteness of our diagnosis) and which only now have come to a fur. they development. They would have developed (perhaps even sooner) if we had not operated. The glands were, in fact, infected before the operation. Hence the very suitable designation " infection 4. Metastatic Recurrences, Metastases.—So much has already been said on this subject that we need not recur to the modern theory of their origin.