TREATMENT OF TUMORS OF THE MAMMARY GLAND.
But since the diagnosis may, for a long time, be doubtful, whether we have to deal with a product of chronic inflammation or with a tumor, the indications are to use such re solvents as iodine ointment, ung. cupri oxyd. nigr., or resolvent plasters and the like. Compression with bandages (suspensorium mamma) or compresses especially adapted to individual cases have been used, and have even been recommended in carcinoma. I cannot support this rec ommendation; for by them we never gain a really complete resorption and cure. The ointments, mixed with pure iodine, too often used, usually act in an irritating manner on those tumors, as does pressure also, espec ially when they already are adherent to the skin. I believe that by them we will sooner promote ulceration and softening than resorption.
If one does not wish to immediately advise an operative procedure, but wishes to watch the course for a time, he may use indifferent ointments or compresses with Goulard's extract (lead-water), in order that the patient may be quieted by the belief that something is being done for her; or he may use some favorite plaster, which has perhaps helped an aunt or a cousin, in case it contain no substance irritating to the skin; simple cover ing of the carcinomatous ulcer with wadding or with a cat's skin suffices to protect it from pressure or blows. When a definite diagnosis and prog nosis has been made at the beginning, or as soon as a definite prognosis can be given, we should be so much the more positive in advice and action.
As a general rule, I might lay it down as a maxim, that every continu ously growing tumor should be extirpated, of whatever nature it may be.
In stabile tumors (small fibromas) and shrinking scirrhus in old women, we need not insist on an operation, though there is seldom any ground for refusal, if it is wished. As regards specially the benign tumors (in Volution cysts, adenomas, adenoid sarcomas, fibroids and cysto-sarcomas) they should be removed, because by their growth they gradually become' more embarrassing, and also because it is not impossible that from some irritation or other, these tumors may take on the character of malignant medullary carcinoma, or, in later years, of carcinoma with rapid course. There are plenty of cases from older and recent times which show that tumors which for years had every appearance of being benign, later took on a malignant character. In regard to this, there is scarcely a difference of opinion, even though this idea rests more upon the statements of the patients than upon direct observation by physicians. Having a tumor has usually a depressing influence upon every woman, and on this account it is humane to free them from the tumor, for there is, on account of the great frequency of cancer of the breast, the fear that a cancer might de velop from the-induration. There are many women who are more relieved when the physician decides for them, whether a stabile tumor shall be retained or removed, than when it is left to their own decision.
In cancerous tumors I would advise immediate extirpation so long as we can remove the whole of the appreciable mass of tumor without pre sumptive danger to life. It is certainly true that many slow growing tumors of this kind may be considered as innocuous for a long time; but then, the right moment for extirpation may easily be passed over with time. There is no doubt that infection of the lymphatic glands is hin
dered or at least diminished by early and thorough removal of the mam mary cancer. Still, even when the lymphatic glands are affected and may still be extirpated, the operation should be done as quickly as possi ble; for, perhaps in this way, general infection, even if not prevented, will be deferred much longer, inasmuch as the new arrival of infectious material will be prevented. Recurrences of tumors of the breast are also to be operated upon, when this can be done with a prospect of removing all of the diseased portion. If the recurrent or primary carcinoma is ad herent to the pectoralis major muscle, this must also be removed in so far as it is diseased. Co-affection of the ribs is in my experience, in those cases in which operation is still a question, rare. In such cases I would scarcely decide on resection of the ribs, as an opening into the pleura under the circumstances would possibly and probably be followed by death from pyothorax; superficial diseased portions of the ribs may be removed without any risk. Operations are usually in vain in cases in which the skin is studded with many nodes and nodules. If the axillary glands are strongly adherent to the vessels and nerves, as shown by the immova bility of the tumor, and by oedema of the arm and by neuralgic pains, the supraclavicular glands being at the same time affected, no further opera tion is indicated. Even the most expert and experienced operator may be deceived as to whether, in a severe case, every portion of the disease is removable. There may thus be differences of opinion between consultants, and also in regard to the question whether an operation should be per formed or not. So too one operator will venture further in such opera tions than another. It cannot be said, absolutely, therefore, that cases are not to be operated upon. Older operators are so often discouraged by the frequent and rapid recurrences that they refrain from operating, because they no longer see, any remedy in it, also no anceps remedium. The English surgeons are the most conservative in operating on far ad vanced cases of carcinoma, and the German surgeons, it seems to me, go the farthest in these operations. As regards the cases of compression of the vessels and nerves in the axilla, with the fearful neuralgias in and the indurated elephantiac edema of the arm, such women have besought me, after they had suffered unspeakably, but were otherwise well and in a good state of nutrition, to give them relief or death by an operation. What can we do in such cases? We may divide the whole brachial plexus in the axilla; but as in laying this bare, we might be compelled to per form high ligation of the axillary artery and vein (which would very prob ably be followed by gangrene of the arm—as the collateral circulation, according to recent investigations, is established through the vasa ner vorum), it would perhaps be more rational to exarticulate the arm, which is only an immovable burden, or would be at least after neurotomy. But would this relieve the pain? May not the supra-clavicular glands also exert pressure on the nerves ? In this case the neuralgias would remain after the exarticulation.