The History of the Radical Mastectomy*

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.

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