THE HISTORY OF THE RADICAL MASTECTOMY*

By WILLIAM A. COOPER

NEW YORK

N THE past fifty years two major Pyramid Age about three thousand contributions have been made to years before Christ, and may have been the treatment of cancer of the written by the first known physician, breast. These are: (1) the devel­ the Egyptian Imhotep. In giving “In­ Iopment of the radical mastectomy, andstructions concerning bulging tumors (2) the development of roentgen ther­ on his breast,” the scribe says: apy. Though the value of the radical If thou examinest a man having bulg­ mastectomy was demonstrated almost ing tumors on his breast, (and) thou find- half a century ago, today there is creep­ est that [swellings] have spread over his ing into the medical literature and into breast; if thou puttest thy hand upon his the minds of physicians a trend away breast upon these tumors, (and) thou from radical surgery. Unquestionably findest them very cool, there being no this trend is due to the continued de­ fever at all therein when thy hand touches velopment of roentgen therapy and an him; they have no granulation, they form increasing faith in its efficacy on the no fluid, they do not generate secretions part of certain groups in the medical of fluid, and they are bulging to thy hand, profession. It is not the purpose of the thou shouldst say concerning him: “One present publication to compare the re­ having bulging tumors. An ailment with which I will contend.” There is no [treat­ sults of the two types of treatment, nor ment]. If thou findest bulging tumors in to dispute the value of roentgen ther­ any member of a man, thou shalt treat apy. Rather, the author will attempt to him according to these directions. trace the details and rationale in the development of one type of treatment This translation is followed by a brief of mammary cancer; namely, radical commentary appended by a “modern” surgery. It is hoped that an analysis and physician about 2500 b.c., who ex­ review of events long past may aid in plains: crystallizing our views of the operative As for: “Bulging tumors on his breast,” treatment of cancer of the breast today. it means the existence of swellings on his breast, large, spreading and hard; touch­ Ancient History ing them is like touching a ball of wrap­ It is probably no mere coincidence pings; the comparison is to a green hemat- that the earliest scientific document fruit, which is hard and cool under thy known to modern man deals in part hand, like touching those swellings which are on his breast. with tumors of the breast. This hier­ atic record, known as the “Edwin Smith The commentator makes it appear rea­ Surgical Papyrus,”1 originated in the sonably certain that the original author * From the Department of Surgery of the New York Hospital and Cornell Medical College. Done under a grant from the National Advisory Cancer Council of the U. S. Public Health Service, Washington, D. C. was describing a malignant tumor of And hard tumors appear in the breast, the breast. That the ancients knew of some large and some smaller, these do not mammary cancer and some of its prob­ suppurate, but continually grow harder lems emphasizes the antiquity of the and harder. From these grow hidden can­ disease and its prominence in the minds cers. When cancers are about to come on, the mouth grows bitter, and every thing of medical men of all times. The Egyp­ they eat tastes bitter, and if you give them tians knew of surgery, but there is more to eat, they refuse it, and shut their nothing in the scanty papyri available mouths. They become delirious, their to suggest that they operated upon eyes are hard and they do not see clearly, cancer of the breast. and pains dart from the breasts to the neck Herodotus2 states that Democedes and beneath the shoulder blades, thirst (520 b.c.) cured Atossa, the wife of seizes upon them, the nipples are dry, and Darius Hystaspis, of a growth or swell­ the whole body becomes emaciated, the ing in the breast. Obscurity of the nostrils are dry and stopped up, and are Greek terminology precludes accurate not elevated with respiration. The breath­ knowledge of the diagnosis, but the fact ing is superficial and they lose the sense of that treatment was successfid suggests smell. Also they do not have pain in the that the disease was not cancer. ears, but sometimes convulsions. When they have gone as far as this, they do not It is singular that “the Great Hip­ recover, but die of this disease. pocrates,’3, 4 born in Gos in 460 b.c., who wrote with meticulous detail on It remained for Cornelius Celsus,7 the operative treatment of sktdl frac­ the Roman (30 b.c. to 38 a.d.) to reveal tures, should write so little on the treat­ in his works further detail concerning ment of cancer. In the many works at­ the therapy of cancer in that period. tributed to Hippocrates there are but “Of a Cancer” he wrote as follows: two references applicable to therapy of There is not so great danger of a cancer, cancer. These are: unless it be irritated by the imprudence It is better to give no treatment in cases of the physician. ... Its general progress of hidden cancer; treatment causes speedy is this; first appears what the Greeks call a death, but to omit treatment prolongs life. cacoethes, then it becomes a carcinoma, Those diseases that medicines do not without an ulcer. From that an ulcer; and cure are cured by the knife. Those that from an ulcer a thymium. the knife does not cure are cured by fire. None of these can be removed but the Those that fire does not cure must be con­ cacoethes; the rest are irritated by every sidered incurable. method of cure; and the more violent the operations are, the more angry they grow. There are also in Hippocrates two di­ Some have made use of caustic medicines; rect references to cancer of the breast. others of the actual cautery; others cut The first appears in “Epidemics /”5 them out with a knife. Nor was any person and again in “Epidemics VII,” and ap­ ever relieved by medicine; but after cau­ parently refers to the same case: terizing, the tumors have been quickened A woman in Abdera had a carcinoma of in their progress, and increased till they the breast and bloody fluid ran from the proved mortal; when they have been cut nipple. When the discharge stopped she out, and cicatrized, they have notwith­ died. standing returned, and occasioned death. Whereas, at the same time, most people, The second is found in “Diseases of by using no violent methods to attempt Women’’:0 the extirpation of the disease, but only applying mild medicines, to sooth it, pro­ arteries, there is immediate danger of tract their lives, notwithstanding the dis­ hemorrhage, but if you use ligatures, ex­ order, to an extreme old age. But nobody tension of the disease to the surrounding can pretend to distinguish a cacoethes, parts takes place. If we elect to cauterize which is curable, from a carcinoma, which the roots of the tumor, there is also no is not, otherwise than by time and experi­ small danger connected with this when ments. the cauterization takes place close to im­ Therefore, so soon as this disease is per­ portant organs. But in its beginning as I ceived, caustic medicines ought to be ap­ have said, we have often cured this dis­ plied; if the disorder is alleviated, and its ease, especially when the melancholic symptoms grow milder, we may proceed tumor is not excessively thick. This read­ both to incision and the actual cautery; if ily yields to cleansing remedies, with it is immediately irritated, we may con­ which it is treated. clude, that it is already a carcinoma; and The earliest detailed description of every thing acrid and severe is to be taken away. . . . an operation on the breast is attributed by Aetius to Leonidus11 (circa 180 a.d.) Galen8,9> 10 (131 a.d. to 203 a.d.), the of the Alexandrian school, and appears most important of the ancient com­ in the “Epitome of Medicine” of mentators on Hippocrates, was more Paulus Aegineta (625-690 a.d.): inclined to the surgical treatment of Laying the patient in a supine position, cancer than were his predecessors, and I make an incision into the mamma above the first description of an operation for the cancer, and immediately apply a cau­ cancer must be attributed to him: tery until an eschar be produced to stop the bleeding. I then make another incision If you attempt to cure cancer by surgery, deep into the substance of the mamma, begin by cleaning out the melancholic and again burn the parts, and so proceed tumor by cathartics. Make accurate inci­ —first cutting and then burning alter­ sions surrounding the whole tumor so as nately, in order to restrain the bleeding. not to leave a single root. Let the blood In this way there is no danger of hemor­ flow and do not check it at once, but make rhage. After the amputation is completed pressure on the surrounding veins, so as I again burn the parts until they are quite to squeeze out the thick blood. Then treat dry. The first burnings are for the sake of as in other wounds. the bleedings, and the last with the inten­ We have cured cancer in the early tion of eradicating the disease. stages, but after it has reached a large size no one has cured it without operation. Caustics were used in the treatment We have often seen in the breast a of cancer by the Greeks and Romans, tumor exactly resembling the animal and were highly developed by the called the crab. Just as the crab has legs on Arabian surgeons. In the Dark Ages both sides of his body, so in this disease of surgery (13th to 16th centuries) the the veins extending out from the unnat­ use of caustics flourished, largely under ural growth, take the shape of a crab’s the influence of Henri de Mondeville, legs. We have often cured this disease in and arsenic or zinc chloride paste re­ its early stages, but after it is grown to a noticeable size no one has cured it with­ mained a major and often recom­ out surgery. In all surgery we attempt to mended type of treatment for mam­ excise a pathological tumor in a circle, in mary cancer well into modern times. the region where it borders on the healthy These are the highlights in the an­ tissue. On account of the size of the ves­ cient history of cancer of the breast. sels, especially when they happen to be Though the knowledge of tumors was extended considerably during the next mammary cancer by compressing the thousand years, little progress was made base with lead plates, as did Leonard in the treatment of mammary cancer, Fuchs,18 a German, born in 1501. and we find that the cautery-excision A11 inventive note in the treatment method of Leonidus, the use of caus­ of cancer of the breast must be ascribed tics, or some variation thereof, per­ to William Clowes18 (1560-1634), physi­ sisted until well into and in some in­ cian to Queen Elizabeth, who reduced stances beyond the seventeenth century. the ritual of treatment to the simple expedient of the laying 011 of hands. Dark Ages Thousands of cancers were touched by Among conservatives the Galenic the good Elizabeth, in the hope that theory dominated treatment, and most they would thereby disappear. And surgeons advised dieting, bleeding and Clowes no doubt was as near the truth purging in efforts to rid the body of the as was James Cooke20 (1614-1688) who melancholic humors. Some concept of a few years later advised bleeding from the stagnation of thought is obtained the basilic vein, or Peter Lowe21 who from rare old surgical works that re­ in 1597 was suggesting the application flected the views of that period. We of goat’s dung. find that Lanfrank,12 the father of The lack of progress was no doubt French surgery, in about 1296 a.d. was closely allied to the persistence of the using the method of Leonidus, and, humoral theory of etiology adhered to quite wisely, favored operation only by Galen, who considered that cancer when the entire tumor could be re­ was caused by the accumulation of moved. Henri de Mondeville,13 who black bile. Nor was the influence of died in 1320 a.d., favored deep inci­ the Church following the Council of sion, extirpation and cauterization in Tours in 1162 conducive to the dis­ smaller cancers, and became proficient semination and advancement of sur­ in the use of arsenic and zinc chloride gical knowledge. A wave of religious paste. Andreas Vesalius,14 professor in fervor put a ban upon “the barbarous Padua in 1537 111 ^e earb Renaissance, practice” that lasted well into the fif­ was one of the first to attack Galen’s teenth century. It was a kindred spirit theory. He excised cancer widely and, of righteous indignation that estab- unlike his predecessors, controlled lished_SL_Agatha as the patron saint of bleeding with ligatures. Fabricus diseases of the breast. The story of her ab Aquapendente15 (1537-1619) per­ martyrdom,22 which has often been formed radical excisions if the patient painted, goes back to 251 a.d. when the insisted, and decried partial excisions Emperor Dccius, in an effort to salve as useless. Marcus Aurelius Severinus16 his conscience, was persecuting the (1580-1656) of the Salerno School per­ Christians. Under this pretense Quin- formed radical excisions for cancer of tianus, his governor on the Island of the breast, and was one of the first to Sicily, endeavored to satisfy his lust on remove the enlarged axillary nodes. the beautiful Agatha from Catania. Ambroise Pare17 (1510-1590) treated Remaining true to her Christian be­ ulcerating cancers with salves. The liefs, Agatha was mercilessly tortured small tumors he excised completely and by having her breasts mutilated. cauterized the bases with vitriol. He Through extraordinary faith the also tried, without success, treating wounds miraculously healed in four days, and Agatha lived, only later to standing of the pathology of mammary die from being rolled on hot coals cancer that would warrant their usage. (Fig. 1). It is likely that they facilitated rapid

Middle Ages mastectomy in a period when, lacking Though the teachings of many of anesthesia, speed was essential. These these old masters were sufficiently retro­ methods are listed and illustrated in the grade to make one despair of progress, following paragraphs: a spark of surgical imagination re­ Johann Schultes23 (1595-1645), com­ mained which found expression in the monly known as Scultetus, was a con­ development of new methods, which temporary of the father of German sur­ were widely accepted and used in the gery, Wilhelm Fabry, and is famous for seventeenth and eighteenth centuries. his “Armamentarium Chirurgicum” There is some question as to whether (Ulm, 1653) wherein is illustrated a these operations were adopted because method of amputation of the breast of their thoroughness or because of that was widely practiced and known their convenience. In sacrificing all of as the method of Scultetus. Ropelike the breast and overlying skin the cords facilitated amputation by holding methods certainly preceded any under­ the breast away from the thoracic wall, and though crude, the method was thor­ was adopted by many of his contem­ ough as far as the primary tumor was poraries (Fig. 5). concerned (Fig. 2). As the art of surgery developed, these *

Wilhelm Fabry24 of Hilden, better methods, which must have resulted in known as Fabricius Hildanus (1560- some cures, were largely abandoned for 1634), studied surgery at Cologne the less brutal and unfortunately less under Casmas Slotanus, a pupil of thorough operations of local excision Vesalius, from whom he no doubt with preservation of adequate amounts learned of Vesalius’ practice of wide ex­ of skin for primary closure. An interest­ cision of mammary cancer. Fabry’s ing account of this period was given by most important work was a collection Moore27 in 1867 when he wrote: of case-records, in which was illustrated It was mistaken kindness which led to a “forcipis et cultelli separatorii” that a change of this mode of operating. Under he developed for amputation of the the influence of a clergyman, who ex­ breast. The instrument constricted the pressed what must have been a prevailing base of the breast while the blade swept horror at such Amazonian surgery, the the organ off the thoracic wall. Fabry practice was changed to an incision in the was probably the first to remove the integument . . . and cancer soon reap­ axillary nodes in cancer of the breast peared. ... In our own day various modes of operating are practiced. Some­ (Fig- 3)- times the tumor only is removed; some­ In 1708 Godefridus Bidloo,25 a times that segment of the breast in which Dutch anatomist and surgeon, illus­ the tumor lies is taken away with it; some­ trated in his “Anatomical and Surgical times the breast is carefully removed; and Exercises” a single and double pronged yet again there being no definite plan in fork that he used in doing a mastec­ the mind of the operator but that of cut­ tomy. The breast was transfixed with ting wide of the tumor. ... t the fork that seemed appropriate, and Modern Period cut away from the pectoral muscles with the ample knife (Fig. 4). As emphasized by Sir D’Arcy Power28 Gerard Tabor26 published “A new in his interesting history of amputation way to extirpate cancer of the breast” of the breast, the credit for introducing in 1721. Tabor’s instrument further a new era in mammary surgery must be simplified rapid mastectomy, and its use given to Jean Louis Petit29 (1674-175°), a prominent French surgeon of that In removing the axillary nodes Petit period. Petit’s “Traite des Operations” was antedated at least a hundred years was not published until 1774, twenty- by Hildanus, and a lesser time by

Severinus, but, like Halsted, he had the advantage of living in a more active period of surgery and having pupils who disseminated and perpetuated his teachings. His work initiated an unin­ terrupted trend toward a more ade­ quate operation on the breast which culminated in the modern radical mas­ tectomy. four years after his death, but his teach­ Benjamin Bell,32 surgeon to the ings became widely known some fifty Edinburgh Royal Infirmary, perpetu­ years earlier through the surgical texts ated the essence of Petit’s views in his of his contemporaries, Rene Garen- “System of Surgery,” which was first geot30 and Lorenz Heister.31 Petit be­ published in 1784, and guided the lieved that the roots of a cancer were practice of surgery in Scotland until the enlarged lymphatic glands, and the middle of the nineteenth century. that these glands should be removed He taught that: along with the pectoral fascia and mus­ When practitioners have an opportu­ cle, rather than leave any doubtful tis­ nity of removing a cancerous breast early sue. When possible he preserved the they should always embrace it, that as nipple and skin, however, and urged little skin as possible should be removed, suturing the lips of the wound to pre­ and that the breast should be dissected off vent hemorrhage and promote healing. the pectoral muscle, which ought to be preserved. If any indurated glands be ob­ would bring surgery into discredit to at­ served they should be removed and par­ tempt extirpation in cases where the ex­ ticular care should be given to this part of tent or connections of the disease pre-

the operation, for, unless all the diseased vented its complete removal. It is also in­ glands be taken away no advantage what­ cumbent upon the surgeon to search very ever will be derived from it. Even when carefully for glands in the course of the only a small portion of the breast is dis­ absorbents that may become affected since eased the whole mamma should be re­ it appears that the result of operations for moved. The axillary glands should be dis­ carcinoma when the glands are affected is sected out by opening up the armpit, but almost always unsatisfactory however per­ as much skin as possible should be pre­ fectly they may seem to have been taken served. I have done this since 1772. The away. The reason of this probably is that older surgeons took away the skin and left the glands do not participate in the dis­ the glands. ' evtzL ease unless the system is strongly disposed to it and consequently their removal, how­ _ James Sym£33 (1799-1870), wrote his ever freely and effectually executed, can­ “Principles of Surgery" in 1842, and not prevent the patient’s relapse. was not as certain as his immediate predecessors of the value of removing As 011c might expect in a period the axillary glands. He says that: when extensive operations were often The only proceeding that deserves at followed by extensive infection, the all to be considered a remedy for cancer outlook among many leading surgeons is removal of the morbid structure. This of the first half of the nineteenth cen­ may be done sometimes by the actual or tury was generally pessimistic. It was potential cautery, but these means are not the fear of sepsis alone that influ­ very apt to destroy the disease only par­ enced their views, but a deeply rooted tially and consequently do no good, but conviction supported by repeated fail­ on the contrary harm, by exciting greater activity in the portion that remains. ures that cancer was rarely curable by The knife or scissors effect the extirpa­ operative measures. So it was that the tion most easily and securely. It would be extension of the operation to include subjecting the patient to useless pain and the axillary nodes as advocated by Petit zwas lost to Robert Liston34 (1794-1847), the United States was an exception in who wrote: this period, for he extended the views Recourse may be had to the knife in of Petit and Bell, and in 1852 empha­ sized that the breast and axillary glands, if involved, should be removed in one piece (Fig. 6). The vacillations in the progress of the operation in one school are well illustrated by the retrograde teachings of Pancoast’s successor at the Jefferson Medical College in Philadel­ phia, Samuel D. Gross.37 who advised that “the proper operation is amputa­ tion, not excision,” but disregarded the axillary nodes. His son, Samuel W. Gross,38 however, swung back to the progressive wing, publishing a book on tumors of the breast in 1880 in which he upheld the radical operation pro­ posed by Moore in 1867, and extended it to include removal of the pectoral fascia (Fig. 7). This brings our story to the contri­ bution of Charles H. Moore27 of the Middlesex Hospital, who, in 1867, pre­ sented a paper, “On the Influence of Inadequate Operations on the Theory of Cancer,” to the Royal Medical and Chirurgical Society in London, in which he said: some cases but the circumstances must be It is not sufficient to remove the tumour, very favorable indeed to induce a surgeon or any portion only of the breast in which to recommend or warrant him in under­ it is situated; mammary cancer requires taking any operation for the removal of the careful extirpation of the entire organ. malignant disease of the breast. When the The situation in which the operation is disease has been of some standing there is most likely to be incomplete is at the edge a considerable risk of the axillary glands of the mamma next the sternum. When having become contaminated. No one any texture adjoining the breast is in­ could now be found so rash or cruel as to volved in or even approached by disease, attempt the removal of glands thus af­ that texture should be removed with the fected whether primarily or secondarily. breast. This observation relates particu­ Sir James Paget35 (1814-1899) was larly to skin, to lymphatics, to much fat, and to pectoral muscle. ... In the per­ equally cautious in defining the limits forming of the operation it is desirable to of the operation, and one is impressed avoid, not only cutting into the tumour, that surgeons of this period were more but also in seeing it. . . . Diseased axil­ conservative in their selection of opera­ lary glands should be taken away by the tive cases than are most surgeons today. same dissection as the breast, itself, with­ Dr. Joseph Pancoast36 (1805-1882) in out dividing intervening lymphatics. Moore’s first contribution to the sub- lesion of the breast, for usually rcmov- ject lends the impression that he did ing the axillary nodes, for championing not routinely remove the axillary nodes, a new cause in a relatively fruitless era

but a few years later he clarified this of surgery of the breast in which the point in some detail: general outlook was despondent, and The period at which cancer is first for initiating a period of rapid devel­ formed in the glands is uncertain, but I opment of the radical mastectomy am led to think it is very early indeed. through a superior clinical insight into I have observed them to be decidedly the pathology of mammary cancer. His tender before they were in any degree en­ teachings were new to his colleagues for larged or indurated. I have met with very they thought that “he combined ex­ few instances in which the glands were treme caution with surprising rash­ not already affected however recent the ness,” and were in general critical of primary disease. So early do they become his recommendations. infected that they can never be assumed Only three years later, however, Jos- to be healthy.28 eph Lister39 (1837-1912) supported and Though Moore was a crusader for a extended Moore’s teaching when he neglected cause, and his thesis is monu­ said: mental in paving the way toward the I have at present a patient about to modern operation, we cannot subscribe leave the Infirmary three weeks after the to the view of many authors that he removal of the entire mamma for scirrhus, founded the radical mastectomy. In all the axillary glands having been at the urging a wide and complete excision same time cleared out after division of of the breast and skin, and practically both the pectoral muscles so as to permit always removing the axillary glands, the shoulder to be thrown back and the his contribution did embrace two of axilla freely exposed as is done in the the elements of the modern operation. dissecting room—a practice which I have It seems that Moore is chiefly to be for some years adopted where the lym­ credited for his radical handling of the phatic glands are affected in the disease. Lister was probably the first to ex­ ingly, entirely removed. I was led to adopt pose the axilla by division of the pec­ this procedure because, on microscopical toral muscles in cancer of the breast, examination, I repeatedly found when I and must, therefore, have been the first had not expected it that the fascia was to execute a meticulous axillary dissec­ already carcinomatous, whereas the mus­ tion. His aseptic technique no doubt cle was certainly not involved. In such cases a thick layer of apparently healthy permitted boldness in this regard. fat separated the carcinoma from the pec­ Mitchell Banks40 used Lister’s carbolic toral muscle, and yet the cancerous spray, and in 1877 took up the cause growth, in places demonstrable only with of cancer of the breast with “A Plea for the microscope, had shot its roots along the More Free Removal of Cancerous the fibrous septa down between the fat Growths,” a cause to which he devoted lobules and had reached and spread itself himself until the progressive times out­ out in flat islands in the fascia. It seems moded his recommendations. He did to me, therefore, that the fascia serves for not extend the operation advised by a time as a barrier, and is able to bring to Moore, and thought it unnecessary to a halt the spreading growth of the car­ divide the pectoralis major, but ably cinoma. campaigned for a complete local opera­ Volkmann’s method of combating tion and was one of the first to empha­ the growth in the pectoral fascia be­ size clearly in 1883 that an axillary dis­ came widely accepted by his contem­ section should always be done. In this poraries in Germany, and by Gross in regard Kuster41 may have antedated the United States. But these were Banks, for he started to remove the changing and progressive times in axillary nodes routinely in 1881. It is which new methods were quickly over­ likely, however, that Banks followed shadowed by further discoveries. this practice some years before report­ Trother Heidenhain43 of Berlin was ing it in 1883, and that in practice both the first to confirm Volkmann’s obser­ were antedated by Moore. vations when he wrote in 1889: There followed a rapid succession of I am firmly convinced from what I have events of profound importance to the seen that carcinomata when they have ac­ development of the radical mastectomy. tually made their way into the lymphatic Volkmann42 in 1875 contributed the channels, and such is usually the case, next progressive step when he wrote: have invariably sent their outposts at once I make it a rule never to do a partial to the surface of the muscle, no matter amputation for cancer of the breast, but what the thickness of the layer of fat be­ remove the entire breast even for the tween breast and muscle may have been; smallest tumors, and at the same time I in other words, that a tumor, however take away a liberal piece of skin. The skin freely movable on the underlying parts, defect is, of course, very great when one has almost certainly advanced as far as operates in this manner, and the wound, the surface of the muscle. in consequence, requires a long time for Heidenhain was further convinced healing. Furthermore, in making the lower incision I cut right down to the by his microscopic studies that cancer pectoralis muscle and clean its fibres, as did not always stop at the fascia, but I would for a class-room dissection, carry­ frequently extended along the vessels ing the knife parallel with the muscular and lymphatics into the spaces between fasciculi and penetrating into their inter­ the muscular fibers. In several instances stices. The fascia of the muscle is, accord­ where the tumor was adherent to the muscle he hypothecated that contrac­ noted presented some unexpected find­ tions of the muscle might easily spread ings. In nine specimens it could be deter­ the malignant cells throughout the lym- mined that the muscle was involved

phatics of the pectoralis major. Heiden- grossly. In a few instances the microscope hain was thereby led to recommend did not disclose muscle involvement when extension of Volkmann’s operation to it was suspected from the gross appear­ include routine removal of the super­ ance; the pectoral fascia although greatly ficial layer of the pectoralis major, and thinned out and compressed seemed to limit the disease even in very large tumors. in cases where the tumor was attached I11 five specimens in which the tumor was to the muscle, removal of the entire not in contact with the fascia, metastasis muscle up to the clavicle. to the muscle occurred; these growths These fundamental observations of were situated 1 cm., 1.5 cm., 2 cm., 3 cm., Volkmann and Heidenhain have since and 4 cm. from the fascia respectively. In been supported and extended by those many of the large ulcerating carcinomas of Stiles,44 Handley,45 Lockwood40 and extending from the skin to the fascia and Speese.47 In 1915 Speese studied the in­ apparently to the muscle, the latter was volvement of muscle in one hundred free from involvement; on the other hand, consecutive operative specimens of in some of the small tumors, not grossly mammary cancer, in which he found: in contact with the fascia or muscle, the On miscroscopic examination, 25 of the microscope revealed the presence of meta­ specimens showed involvement of the mus­ static cells in the pectoralis major. cle by cancerous extension, and of these The facts gained from this study do the fascia was involved in 18. In 19 the not present anything distinctly new; they pectoral fascia contained the evidence of serve, however, to call our attention to the cancer and the muscle was free; therefore, importance of the complete operation. we find that in 37 instances the pectoral Certainly when so large a number of the fascia was involved. Further study of the cases show muscle involvement, when we specimens in which muscle metastasis was are unable to foretell which tumor will metastasize to the pectoral muscle, it is With the exception of perhaps Billroth, better to remove the latter, minimize the Volkmann is the only one of the surgeons danger of local recurrence, and avoid the quoted who occasionally removed the pec-

far greater danger of further dissemina­ toral muscles. But his operation is an im­ tion of the cancer by contraction of the perfect one. It admits of the frequent muscle in which the cancer cells may lie. division of tissues which are cancerous and it does not give the disease a sufficiently Unfortunately, Volkmann’s observa­ wide berth. Why should we shave the tions in miscroscopic pathology stopped under-surfaces of the cancer so narrowly short of the pectoral muscle. Had he if the pectoralis major muscle or a part been aware of the whole truth, it is of it can be removed without danger, likely that his name rather than Hal- and without causing subsequent disabil­ sted’s would have lived to be associated ity, and if there are positive indications with the modern operation. for its removal? It remained for William Stewart Hal- sted (1852-1922) at the Johns Hopkins Continuing, he says: Hospital in Baltimore to construct out The pectoralis major muscle, entire, all of this sizable background of detail a except its clavicular portion, should be practical solution of the problem. So it excised in every case of cancer of the was that in 1882 Halsted began to prac­ breast because the operator is enabled tice an operation that embodied the new thereby to remove in one piece all of the principle of routine complete removal suspected tissues. The suspected tissues of all but the clavicular portion of the should be removed in one piece lest the pectoralis major muscle. This was first wound become infected by the division reported briefly in 189048 and in detail of tissue invaded by the disease, or by in 189449 (Figs. 8, 9). Halsted said: division of the lymphatic vessels contain­ ing cancer cells, and because shreds or out this maneuver. In fact, Joerss at­ pieces of cancerous tissue might readily be tributes the modern operation to Hei­ overlooked in a piecemeal extirpation. denhain. Halstcd, however, was clearly

The rationale of Halsted’s attack on the first to recommend routine removal cancer of the breast was directed largely of the muscle. at the proposition of preventing local Only ten days after Halsted’s paper or regional recurrences. In a brilliant was published, Willy Meyer51 (Fig. 10) paper presented before the Clinical So­ presented before the New York Acad­ ciety of Maryland in 1894,49 he analyzed emy of Medicine on November 12, the recurrences of the German surgeons 1894, a similar operation, in which he of that period, and demonstrated the further advocated the routine removal value of his operation in this regard. of the pectoralis minor muscle. The That the prevention of local or regional essential differences in the two opera­ recurrences has enhanced the possibil­ tions were the skin incision, removal ity of five year cures has since been of the pectoralis minor, and the direc­ amply demonstrated. tion of the dissection, Meyer progress­ Halsted was not the first to remove ing from the axilla medially. the pectoralis major muscle in doing a Precedence for the modern mastec­ radical mastectomy. As early as 1570 tomy is clearly given to Halsted, for at Barthelemy Cabrol,50 professor in the time Meyer published his opera­ Montpellier, reported the cure of a tion Halsted was studying end results. mammary cancer in a woman of thirty- Both authors modified their procedures five, in which the pectoralis major mus­ with further experience, Halsted ac­ cle was excised and the wound sprin­ cepting Meyer’s treatment of the pec­ kled with vitriol. The patient lived toralis minor, and Meyer adopting the twelve years, only later to die of can­ Thiersch graft as a method of closure, cer of the lower lip. Petit and many until finally the two operations differed of his successors occasionally removed only in the form of the skin incision. portions of the pectoral muscle in cut­ For a time Halsted advocated dissec­ ting wide of certain malignancies of the tion of the neck as a routine accom­ breast, and Volkmann and the Germans paniment of his mastectomy, but later of that period not infrequently carried abandoned this practice. In its final form the technique of the For all essential purposes the ana­ radical mastectomy of Halsted embod­ tomical limits of the radical mastectomy ied the principles of: have been reached. Whatever improve­ 1. Wide excision of the skin, cover­ ment is shown in more recent series ing the defect with Thiersch treated surgically must be ascribed to grafts. either the more timely or the more 2. Routine removal of both pectoral thorough application of the operation. muscles. Results 3. Routine axillary dissection. 4. All tissues being removed in one Fhe results of these varied opera­ block, cutting as wide as possible tions are shown in the following table. on all sides of the growth.* Unfortunately the earlier authors were vague regarding their cures and the fig­ Rhe history of the radical mastec­ ures for simple mastectomy are there­ tomy since Halsted’s contribution is fore scanty. In the last half of the past tedious and complex. Many technical century studies of results at the end of modifications have been introduced, three years, if any, were the vogue. most of them dealing with the form of That the modern figures may be com­ the cutaneous incision, or other details parable, therefore, the three year period of relative unimportance. Particularly is accepted as the arbitrary time for worthy of mention is Handley’s45 modi­ measuring the end results in this pub­ fication, based upon his thorough study of the modes of dissemination of cancer lication. Fhe figures in the table ex­ of the breast. Handley urges the re­ press the results in entire series of moval of lesser skin areas and greater operable cases. No effort has been made fascial areas than did Halsted, particu­ to separate the series into early or late larly in the epigastrium. The value of groups. It would be impossible so to these many modifications of Halsted’s classify the earlier series accurately, and procedure lies in the fact that they would only confuse a broad view of the served to keep the essentials of the problem. radical mastectomy in the foreground An historical analysis shows through throughout the surgical world, while the past century a progressive increase the unimportant details remain a mat­ in the percentage of cures of mammary ter of opinion and experience. The cancer, roughly but definitely parallel­ principles of the modern operation ing the development of the radical have in general been accepted, but the mastectomy. The obvious interpreta­ execution of these principles finds tion is to attribute these improved re­ many surgeons falling short of the ideal sults to more adequate surgery. That in which they profess to believe. The other factors are involved, and that this very nature of the modern operation interpretation may be questioned, is contains so many features requiring well expressed by Ewing64 as follows: meticulous attention to detail that faithful adherence to its principles can­ The high proportion of clinical cures from the modern operation has resulted not be overemphasized. largely from the earlier recognition of * A detailed description of the Halsted cancer, and the inclusion of a larger num­ mastectomy will be the subject of another ber of minute carcinomas or precancerous publication. lesions in the operated class. Type of Operation Author Year L1 r 1,’n1 Gases 3 year Cures

1. Simple mastectomy V. Winiwarter (Billroth)52.... 1867-1875 4.7 Average 4.7

2. Complete mastectomy and axil- Oldekop53...... 1850-1878 229 11-7 larv dissection in majority of Dietrich (Lucke)54...... 1872-1890 148 16.2 cases Horner55...... 1881-1893 144 19.4 Poulsen56...... 1870-1888 110 20 Banks40...... 1877 46 20 Schmid (Kuster)41...... 1871-1885 21.5 Average 18. 1

3. Complete mastectomy, axillary Sprengel (Volkmann)57...... 1874-1878 200 11 dissection, removal of pectoral Schmidt58...... 1877-1886 112 18.8 fascia and greater or lesser Rotter59...... 30 20 amounts of pectoral muscle Mahler60...... 1887-1897 150 21 Joerss61...... 1885-1893 98 28.5 Average 19.9

4. Modern radical mastectomy Halsted49...... 1889-1894 76 45 Halsted62...... 1907 232 38.3 Hutchison’s collected figures63. 1910-1933 39-4

That earlier treatment has increased In so disposing of the time element, the curability of breast cancer is un­ the modern end results are at a disad­ questioned. This is strikingly illustrated vantage, but none the less demonstrate by the high percentage of cures by sur­ gery alone in cases having no axillary Per Cent 3 Year involvement (71.3 per cent 5 year cures Operation Cures according to Hutchison03). With the 1. Simple mastectomy...... 4.7 2. Complete mastectomy and axillary dis­ methods of treatment available at the section...... 18.1 present time, propaganda for earlier 3. Complete mastectomy, axillary dissec­ tion, excision pectoral fascia and vari­ treatment seems the most effective able amounts of muscle...... 19.9 weapon in combating cancer of the 4. Modern radical mastectomy (Hutchi­ breast. The thesis son’s63 collected figures for cases with present is not to dis­ axillary metastases)...... 36.0 pute the value of early treatment, but to demonstrate that the extent of the a marked improvement which can only operation has been equally important be due to a more adequate operation. in contributing toward improved end results. The advantages of the radical Conclusion mastectomy are clearly shown in the Ihe development of the modern previous table. To lend credence to operation was a laborious and tedious the argument and further clarify the process which started with Petit in 1739 issue, it is assumed that all cases treated and ended with Halsted in 1890. The before Halsted’s time were sufficiently story is not one of orderly progression, advanced to have axillary metastases. but is fraught with retrogressions that These cases are compared with modern are prominent even today. The horror series having axillary involvement of sepsis, the need of anesthesia, and treated by radical surgery alone, in the the wide acceptance of the incurability following table. of cancer were prominent in delaying the development of surgery of the roentgen therapy nor radium in any of breast. To attribute the modern opera­ its known forms can be relied upon to tion to any one individual is to dis­ eradicate either the primary or the sec­ credit the vast experience of his prede­ ondary growths in cancer of the breast. cessors, as reflected in the accumulated The physical agents may cause regres­ literature of the ages. The earlier pio­ sion, and not infrequently seem to deter neers extended the operation because the growth of mammary cancer, but of clinical observations on the natural rarely do they prove lethal to the tumor history of the disease. They lacked the as radical surgery frequently does by background of pathological, anatomical removing all traces of disease from the and statistical detail that was to enable patient upon which it grows. It is prob­ Halsted years later to complete the ably trite to mention at this point that evolution of the radical mastectomy. surgery too is an unreliable method of Now, almost fifty years after the treatment. This is not the fault of the emergence of the radical mastectomy radical mastectomy, but of the disease in its final form, certain recommenda­ which it treats. It is well to bear in tions appear in the surgical literature, mind that surgery is capable of curing which, as far as the completeness of the one hundred per cent of the cases in operation is concerned, take us back to which the disease has not spread beyond the procedures of Scultetus and others the mechanical limits of the operation. in the Middle Ages. Borak,65 Grace,66,67 Let us then, as surgeons, internists, and Erskine68 in this country suggest roentgenologists, and general practi­ simple mastectomy to be followed by tioners, use the radical mastectomy to roentgen therapy, while Fitzwil- its fullest limits, and use roentgen ther­ liams69, 70 and Rowntree71 in England apy not to mop up what the careless would perform a local excision to be surgeon leaves behind, but to hold in followed by the application of radium, check that which the most meticulous or simply apply roentgen therapy. surgeon cannot remove. A complete un­ These recommendations are supported derstanding of the history of the devel­ by neither experience nor sound judg­ opment of the operation and a thor­ ment, and thereby invite attack. It is ough appreciation of the life history of generally recognized by roentgenolo­ cancer in the breast, surely can lead to gists and pathologists alike that neither no other conclusion.

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