While according to the older opinions the operation looking to the cure of the evil was absolutely hopeless, since the measures which are taken to free the supposedly diseased blood from the peccant material, even though used diligently, only disappointed, while the operation seemed even harmful, the more recent views give us the certain hope that the primarily, purely local disease can be entirely cured by the radical re moval of the tumor, except in those rare cases in which carcinomata occur at the same time, or in succession, but independently of one another, in one and the same organism. If the operator can remove the carcinoma tously degenerated part completely without injury to the most important functions of the organism, the patient is really cured of the " cancerous disease." From this it is self-evident that it is our duty to remove all carcinomas that can be operated on, as early as possible. But when is that moment when we dare hope that we have really cured the patient of the frightful disease ? In order to know this we must learn how soon recur rence generally appears in this or that form. Regarding this there are a number of careful researches.
Weeden Cooke, by comparison of 413 operated cases of carcinoma of the mamma, found that 409 remained free from recurrence for 64 months, and later recurrence occurred in 4 cases.
Benjamin calculated, from 80 cases, an average of 44 months. Von Winiwarter has also given very detailed data on this point. I will only mention here that according to his calculation from 91 cases, recurrence took place in 27.4 per cent. before closure of the wound, in 38.4 per cent. within the first month, and in 34.1 per cent. later than the first month; in these last cases there were so many recurrences in the first three months after the operation that the total of the recurrences which appeared within the first quarter of a year after the operation amounted to 82.4 per cent. of all cases. All were doubtless continuity and infec tion recurrences. There remain 11 cases in which recurrence first be became noticeable between the eleventh and twelfth month, and five cases in which recurrence first appeared 11 (2), 2 (2) and 31 years after the operation. It is difficult to judge of the nature of these last cases; we may either regard them as arising from long inactive remainders or as new affections, as regional recurrences.
The results of all these researches very strongly support the following position of Volkmann: " If a whole year passes after the operation, with out a local recurrence, glandular swelling or symptom of internal affection being demonstrated on most careful examination, we may begin to hope that a permanent, good result has been obtained, of which we are usually certain after two years, and, almost without exception, positive of after three years." I believe that we may be somewhat bolder and assert that if, by the examination of an experienced surgeon, it is shown that there is no recognizable recurrence one year after healing of the wound, we may be certain that neither a continuous nor an infectious recurrence will appear, and the patient may be regarded as radically cured. For
the rarely occurring new affections, the so-called regional recurrences in carcinoma, we can set no time limit. I must especially emphasize the fact that the examination, chiefly of the axillary space and of the supra clavicular region, should be made by one who, in consequence of his ex perience, has such a fine sense of touch, and the ability to bring the body into such positions as aro most favorable for examination, and can find the smallest nodules.
If now the number of cures proved in this way has hitherto always been unfortunately relatively small, it is because the physicians who do not operate themselves always wait too long before impressing upon their patients the necessity for the operation, or both they and the patients, as I have seen, far too often, trust to the diagnosis " chronic mastitis," or refer to cases in which the development of carcinoma went on for years, or hold to the opinion that the evil is certainly incurable, so why torment the patients with operations. With the above given results, we may to day predict with certainty that this will be better in a short time. The operation has lost much of its terror to patients through narcosis; the loss of blood, by modern technicalities and practice, is reduced to a very small quantity; the danger to life is minimized; the pains, on account of the modern antiseptic dressings, are insignificant, and the time required for healing has been reduced to one-fourth or less. All this, conjointly with the conviction of physicians, must show that operation and only operation can give a permanent cure, that we always attain more and more favorable and complete results as to cure. Of course there always will be individual cases of carcinoma of the mamma, in which (as in the greater number of carcinomas of the tongue and floor of the mouth) the infection of the lymphatic glands follows so very quickly that it already exists before the diagnosis can be positively made, and these will always remain incurable; but these are rare and fatal exceptions.
I have seen in my experience 15 authenticated cases of mammary car cinoma, in which 12, 6, 5-h, 4, 2, and years passed after the last operation, without there being any recurrence, and Volkmann has had a number of such cases; it will probably be allowed that we made correct diagnoses. I know from my own observations that we should not despair of a radical cure so long as there is a prospect of removing all the disease, as in only a few of the cured cases was the operation a simple one, confined to the mam ma. In most cases the axillary glands had to be extirpated; in many cases radical cure resulted only after a second operation, and in one case only after a third.