HOW SHALL WE OPERATE FOR MAMMARY 
CANCER. AND WHEN? 
BY 
DOUGLAS MORTON, A.M., M. D. 
Consulting Gynecologist to the Louisville City Hospital. 
Reprint of the American Practitioner and News. 
LOUISVILLE: 
John P. Morton and Company. 
1891 HOW SHALL WE OPERATE FOR MAM- 
MARY CANCER, AND WHEN?* 
At a meeting of the Medico-Chirurgical Soci- 
ety last summer I exhibited three mammary tu- 
mors I had recently removed, and at a meeting 
later on another, removed a few days before. 
More or less interest attached to all these tu- 
mors intrinsically; but my purpose this even- 
ing is not to discuss the tumors, but the method 
of their removal. The breasts had been ampu- 
tated by the old method, leaving the axilla in- 
tact, except in one case in which I removed 
several greatly enlarged axillary glands. 
In the discussion that followed most of the 
members expressed emphatically their prefer- 
ence for the " completed operation." I ob- 
jected that the " completed operation" is not 
only far more dangerous than the old one, but 
in an important sense is incomplete after all. 
As it is usually done, the axillary glands and 
some tissue about them are removed. The in- 
tervening lymphatic ducts, that may be full of 
*Read before the Louisville Medico-Chirurgical Society, 
June 24, 1891. 2 
cancer cells, especially at their valves, are at 
best only partially removed ; the alveolar buds 
that shoot out from every gland from the mo- 
ment it enters the process of becoming fixed 
are cut or torn through, causing cancer cells to 
be scattered over the surface of the wound, 
soon to become fixed as new foci. Further- 
more, the supra- and sub-clavicular glands that 
in many, perhaps most of the cases become in- 
fected sooner or later are in the "completed 
operation," as it is ordinarily done, left intact; 
even Gross, a most earnest advocate of this 
operation, removes these glands only when they 
are palpably enlarged. I mentioned a case that 
represents a large proportion of all mammary 
cancer cases, in which I removed the breast 
without opening the axilla, some years ago. 
Two years later I removed enlarged supra- and 
sub-cl ivicular glands, the axillary glands hav- 
ing in the mean time enlarged very little-too 
little to have attracted the patient's notice. 
Since the discussion referred to, I have taken 
pains to'examine this subject more thoroughly, 
and have come to the conclusion that Butlin 
uses a not too strong expression when he calls 
the " completed operation" a "surgical blun- 
der." 
In order to examine systematically the con- 3 
ditions that bear upon the question of "clearing 
out" the axilla, all mammary cancer subjects 
may be divided into four classes: (1) Those in 
which the disease has not only infected the ax- 
illary glands, but by metastasis or otherwise 
has involved internal tissues and organs; 
(2) those in which these glands have become 
infected, but in which the disease has gone no 
further; (3) those in which metastases have 
occurred without infection of the glands; 
(4) those cases in which the disease is as yet 
limited to the mamma. 
It is clear enough that every case belongs to 
one or the other of these classes, but of course 
it may be impossible to determine to what class 
any given case belongs. Practically, however, 
the doubt in any case must be held as against 
the operation of opening the axilla. This will 
become more apparent further on. 
The cases of the first class are plainly not 
operable. 
In those of the second, if clearing out the 
axilla and removing every gland in the whole 
neighborhood of the diseased breast and the 
tissue around them as well were to complete 
the operation as the term implies, it would 
certainly be justifiable, provided the mortal- 
ity after this procedure be not too great. As 4 
to the pertinency of this proviso, let us see 
what the " completed operation " really in- 
volves : 
"According to Mr. Banks, of Liverpool, one 
of its oldest and most earnest advocates, the 
attitude of this innovation in regard to removal 
of a cancerous mamma is that the integuments 
are to be sacrificed without heed to the question 
of covering the wound, that the fascia is always 
to be dissected from the pectoral muscle with as 
much fiber of the latter as may be deemed ad- 
visable ; and whether involved or not the ax- 
illa is to be cleared, not merely of glands, but 
of all its tissues-nerves and vessels excepted- 
with a completeness equaled only in a dissec- 
tion for anatomical demonstration." (R. M. 
Hodges, Boston Medical and Surgical Journal, 
November 29, 1888.) 
Dr. Gross, in his admirable paper (American 
Journal Medical Sciences, April, 1888), writ- 
ten, as it appears, much for the purpose of 
setting forth the advantages of the " completed 
operation," gives statistics of local recurrences 
as follows: 
Of 409 cases, partial or total extirpation of mamma 
without glands was done in 96 cases. 
Recurrence in or near cicatrix, 46 cases = 47.91 p.ct. 
" cicatrix and glands, 31 cases = 19.79 " 
glands alone 19 cases = 32.29 " 5 
Of amputation of breast with removal of glands, 
313 cases. 
Recurrence in or near cicatrix, 235 cases - 75.08 p. ct. 
" glands alone 38 cases = 12.14 " 
" both places 40 cases - 12.77 " 
In connection with this table Dr. Gross says 
there are two interesting practical facts. In 
the first place, where the breast and glands are 
removed, the disease reproduces itself in an 
average of 6.4 months, while, when the breast 
alone is extirpated, recurrence follows in 7.7. 
Secondly, in the former operation, the axillary 
glands are the seat of recurrence in twenty-five 
per cent of all cases, while they are affected in 
fifty-two per cent of the incomplete operations. 
Hence he concludes, "that by clearing out 
that cavity in all operations we may naturally 
expect to diminish if not prevent further local 
dissemination." 
Holding a different view from that of Dr. 
Gross as to the advisability of clearing out the 
axilla, I can not reach the same conclusion 
from these premises. In the first place, it is 
seen by his own figures that recurrences in 
glands take place about half as often after the 
completed operation as after the operation that 
does not touch the axilla. In the second place, 
by the same figures, there are over fifty per 
cent more recurrences in and near the cica- 6 
trix after the former than after the latter 
operation. 
These figures, I believe, show the impossibil- 
ity of doing any operation that deserves to be 
called "completed" after the invasion of the 
axilla has taken place. They show too, that 
the number of local foci, so far from being 
diminished, is actually very much increased. 
These facts, taken with the other very impor- 
tant fact that the immediate mortality after the 
" completed operation " is double (Butlin) that 
after the incomplete, seem to utterly condemn 
the former as a life-saving measure in the class 
of cases under discussion just here. But will 
it lessen the suffering of the patient ? At first 
sight it might be supposed that removal of ax- 
illary glands would prevent the severe suffering 
incident to pressure of these glands upon the 
axillary vein and plexus of nerves ; but as mat- 
ter of fact it simply substitutes a mass of cic- 
atricial tissue for the indurated glands, which 
certainly causes as much pressure as they do, 
and in destroying the continuity of the lymph 
ducts favors rather than otherwise the edema 
of the arm. 
Hodges, in a very able paper, says " Edema 
of the arm, the worst and most distressing in- 
cident of cancer of the breast, rarely fails to 7 
accelerate the fatal event. It is more likely to 
occur when the incision has been extended into 
the armpit than when the disease has been left 
to itself." According to Banks (British Medi- 
cal Journal, December 9, 1882), " it is but 
right that while pleading for an early and free 
operation one should admit that if it fail thor- 
oughly to cure it does not improve the patient, 
but makes her decidedly worse." 
The third class is made up of cases in which 
metastasic tumors have occcurred, and without 
antecedent glandular involvement. These are 
clearly not cases for operation. As to the rel- 
ative frequency of their occurrence Dr. Gross, 
in the paper referred to, has given statistics. 
In one set of 52 cases there were 7 in which 
metastases had occurred without implication 
of the glands. In another set, taken from 
Von Zorok and Wittleshofer, in which " of 191 
cases without glandular involvement metasta- 
sis had occurred in 62.3 per cent." Buttin, in 
his work "On the Operative Treatment of 
Malignant Diseases," says "the proportion of 
cases in which the disease appeared in the ax- 
illa without recurring in or near the scar was 
singularly small, scarcely more than three per 
cent." Thus it is seen that there is a large 
proportion of cases which, before the develop- 8 
nient of cachexia that always sooner or later 
follows the infection of internal organs, may 
seem, on account of absence of glandular impli- 
cation, especially proper for operation, but 
which are absolutely unfit for any kind of 
surgical procedure; and the doubt in regard 
to these cases must most certainly be held 
against doing any operation that is attended by 
a high immediate mortality. 
The fourth class embraces those cases in 
which the cancer is as yet strictly local. By 
almost universal consensus among pathologists 
cancer is at first local, and as long as it remains 
local thoroughly eradicable. Now 1 think that 
it has been satisfactorily demonstrated above, 
that after the axillary glands have once become 
involved it is at least highly improbable that 
the disease can be eradicated from this locality 
by any surgery however thorough ; and this 
truth involves another that is highly probable, 
that the cases in which cures have followed the 
" completed operation " were those in which 
the axilla had never become implicated, and 
were therefore curable by the minor and far 
less dangerous operation properly done. 
Before proceeding to make a comparison be- 
tween the percentage of cures after the respect- 
ive operations, it is but just to Dr. Gross to say 9 
the results obtained in his own 43 cases are the 
best that have been recorded. In these opera- 
tions there were only two fatal cases, 32.55 per 
cent of recurrence in and near the cicatrix, 
and 21.05 per cent of cures. 
Of 311 cases given by Butlin, the breast 
alone was removed in 141, and 12 died of the 
operation. The breast and glands were re- 
moved in 170 cases with an immediate mortal- 
ity of 39. For comparison of percentage of 
cures 242 of the whole number are available, 
98 in the first set and 144 in the second. Of 
these, in the first there were 19 cures tested by 
" the three years limit," and 11 in the second, 
or 19.5 per cent of cures in cases in which only 
the breast was removed, and 6.15 per cent in 
which the breast and glands were removed. 
Buttin gives another set of cases treated by 
Dr. Bougard, of Belgium, with caustics. Of 
162 cases, 62, or nearly 40 per cent, were free 
from recurrence three years after treatment. 
Mr. Buttin was inclined at first to doubt the 
accuracy of these figures, but on thorough ex- 
amination of Dr. Bougard's book became con- 
vinced of their genuineness, and was led to be- 
lieve this unparalleled success to be due to 
the author's careful selection of cases for treat- 
ment. 10 
Bougard's experience indicates the localism 
of the disease in its early manifestation, and 
the possibilities of a treatment that does not 
touch the axilla. 
There is a moral aspect that must not not be 
left unconsidered in the discussion of this ques- 
tion. Every woman with a mammary tumor 
has an indisputable right to a frank and honest 
statement from the surgeon to whom she ap- 
plies of the dangers of the operation he may 
propose and her prospects as to ultimate cure. 
Let us suppose a woman about forty years old 
applies to a believer in the " completed opera- 
tion" with a tumor about the size of a walnut 
she has just noticed for the first time. He 
must tell her the tumor is very probably, 
though not certainly a carcinoma, and that it 
should be removed at once; that the operation 
kills about ten per cent of casesthat, if it is 
done by Gross' peculiar method, she must be 
under treatment for months if she escapes the 
immediate danger of the operation, and finally, 
if she is not radically cured she will be put in 
a worse condition than before. 
I do not believe one woman in a hundred, 
after getting this information, to which she has 
a perfect right, would submit to the " com- 
pleted operation." She would most probably 11 
delay the matter till too late for any operation 
to avail. On the other hand, if the surgeon 
happens to believe that extirpation of the 
breast alone, properly done, is the best pro- 
cedure, he can say, as I firmly believe, there 
need be no mortality at all after the operation, 
save that which may come from shock or from 
the anesthetic; that the patient will recover in 
a week; and finally, that recurrences, as evi- 
denced by a great mass of statistics, are cer- 
tainly not more frequent after this than after 
the other method. There can be no doubt that 
the effect of a general adoption of the minor 
operation will be to encourage women to sub- 
mit to it at the earliest manifestation of the 
disease, and at the time therefore when her 
chances for permanent cure are best. As the 
case stands now, the subjects of mammary can- 
cer, frightened off by the knife in the hands of 
the regular surgeon, are flocking to the quacks, 
who are getting results that, say what we may, 
are sustaining their business wonderfully well. 
In order to give some freshness to this dis- 
cussion I wrote to a number of prominent men 
in different parts of this country, asking data 
obtained in their own experience on two points, 
namely, the relative frequency of serious axil- 
lary complication in mammary cancer; and sec- 12 
ond, the comparative liability of recurrence of 
skin epitheliomas after extirpation by the knife 
and destruction by caustics. The purpose of 
the second question will be seen further on. 
Replies were received from most of these gen- 
tlemen, and though none contained information 
available as statistical material on the first 
point, they nevertheless contained valuable 
matter. On the second point three important 
replies were received. 
As my paper is meant to be short I can not 
devote the amount of space I would like to the 
letters of the gentlemen who have so kindly 
answered my inquiries, but will endeavor to do 
them justice. 
Maurice Richards'on, of Boston, author of a 
very valuable paper on the surgical treatment 
of malignant growths, in the Boston Medical 
Journal, August 30 and September 6, 1888, 
says serious axillary trouble (edema of the arm 
and severe pain from pressure on branches of 
the brachial plexus) occurred in not less than 
half the inoperable cases he had seen. He 
says, further, " I always dissect out the axilla 
in every case, and I have never failed yet to 
find, even in the earliest cases, some infiltration 
these glands." 
Hunter McGuire says, "lam always very 13 
careful to remove any enlarged glands in the ax- 
illa when I operate for cancer." (Italics mine.) 
H. H. Mudd, of St. Louis, writes that in- 
duration (of the axillary gland) "becomes a 
serious factor in perhaps one third or one fourth 
of the cases." He says, further, he makes more 
thorough search for indurated glands than for- 
merly, and rarely fails to find them. When he 
does find them he dissects out the axilla as com- 
pletely as possible. 
Bache Emmet writes, " I have never seen a 
recurrence in cases in which I had even felt 
enlarged glands," and further on, " I have 
never failed to see recurrence when any en- 
larged glands were left." He adds this inter- 
esting statement: "I have several times found 
many glands enlarged, and at a subsequent 
examination, after some months' interval, have 
been unable to find any thing like the same 
number," and this in undoubted cancer while 
in active progress. 
H. O. Marcy writes, "I am sure the axilla, 
in the few non-operative casfes where I have 
known the results, has almost without excep- 
tion become involved," but that " quite a num- 
ber, where the gland was removed early and 
thoroughly, have continued well during a con- 
siderable number of years, although there could 14 
have been little question of the character of the 
disease." 
Conner, of Cincinnati, writes, "I can safely 
say that in nineteen out of every twenty cases, 
the axillary glands have been affected and in- 
fected." 
Ransohoff, of Cincinnati, says, "I believe 
every lymphatic enlargement in the axilla is 
serious in mammary carcinoma. I go even 
further in the conviction that infiltration un- 
disco verable by palpation is present at an early 
period of the clinical histories of these cases; 
on this conviction, I clean out the axilla in 
every case, irrespective of the presence or ab- 
sence of enlarged glands." 
W. M. Polk says, "All my cases have shown 
glandular enlargement in the axilla sooner or 
later; even those operated upon have in the 
end had recurrence, generally in the lung." 
Maury, of Memphis, says, " Out of a dozen 
cases operated on for cancer of the breast, I 
have not seen death or serious derangement of 
health ensue upon axillary involvements." In 
only three of these cases was the axilla cleaned 
out. In the other nine no enlargement of the 
glands was found on careful examination. 
Referring to the strong paper against the 
" completed operation " (loc. cit.), R. M. Hodges 15 
writes, " I have never had any reason, since it 
was written, to modify my opinion, except by 
way of feeling still more strongly its correct- 
ness. I have seen in the columns of the Bos- 
ton Medical and Surgical Journal, in reports of 
Society meetings, some evidence, as it seems to 
me, that those gentlemen in the city who have 
advocated the so-called completed operation are 
weakening on their estimate of its safety and 
justifiability." 
Referring again to the statistics of Gross, it 
will be seen that of 313 amputations of the 
breast combined with extirpation of the glands, 
recurrence was met with in 275, or 87.86 per 
cent. These figures include his own cases, and 
he states that if they are deducted it will be 
found that in 94.47 per cent the disease recur- 
red in or near the cicatrix." Now we learn, 
elsewhere in the paper, that 257 of the 313 
cases of " completed operation " included be- 
sides his own 43 cases those of Banks and Kiis- 
ter; and these two gentlemen, it must be remem- 
bered, are earnest advocates of this operation. 
The conclusion then is necessary, either that 
Gross was far more thorough in his work of 
clearing out the axilla than these other gentle- 
men, or that his greater success was attributa- 
ble to some additional modification. It would 16 
naturally occur to those who believe in Gross's 
"dinner-plate" operation that his success was 
due to his free sacrifice of integument; but 
this was not his own way of thinking, for after 
examining Bank's record he says, "I felt as if 
I had possibly sacrificed too much integument, 
and I have in four recent cases so far modified 
my operation, the skin in none being apparently 
affected, as to save a sufficient amount of that 
structure to admit of bringing the wound nicely 
together without tension." 
It seems then that we must accept the alter- 
ative of Gross's greater thoroughness in clearing 
out the axilla. Though, as his record is small 
compared with the combined records of excel- 
lent surgeons who are as firm believers as he 
in the "completed operation," we are inclined 
rather to the view that he had had an extraordi- 
narily good "run" of cases, in which perhaps 
the axilla was involved in very few. Certainly 
the statistics I have quoted go far to verify the 
statement already made, that where the axillary 
glands have become infected it is very difficult, 
if not impossible, to do an operation that de- 
serves to be called " completed." 
To ray question as to the comparative fre- 
quency of recurrence of skin epithelioma after 
removal by the knife and by caustics, I received 17 
a number of replies, several to the effect that the 
writers had always used the kuife exclusively. 
Among these were Agnew, of Philadelphia, 
who said, however, that recurrences after the 
knife in his experience had sometimes taken 
place in cases of epithelioma on the lower eye- 
lid, near the inner canthus. 
Of those that had used caustics, Hunter 
McGuire said, " I think epithelioma removed 
by caustics or cautery less apt to return than 
when taken out with the knife." Ransohoff 
said, " My experience has led me to value 
highly the use of caustics in superficial epithe- 
liomas of the face, lips, and external ear." 
George Henry Fox says that " extensive cases 
of epithelioma are more liable to return after 
the knife than after the thorough application 
of a caustic." 
My aim in putting this question was to col- 
lect testimony acceptable to the profession as 
to the correctness of the belief held by some, 
that cancer cells infiltrating the tissues sur- 
rounding an epithelioma are destroyed by the 
inflammatory process set up by caustics used 
for the destruction of the growth. I find, how- 
ever, that very few surgeons have used caustics 
and still fewer have written on the subject. 
Bougard, whose cases have been mentioned, 
2 18 
and Dr. J. N. Bright, of Lexington, whose 
very scholarly work on Cancer, Its Classifica- 
tion and Remedies, are all that I know of. 
Dr. Bright wrote, loc. tit. p. 11, that after 
using the knife twenty years he became dissat- 
isfied and disheartened, gave it up, and turned 
his attention to a more thorough research into 
the nature of cancer and a different mode of 
treatment. He devotes a chapter to his record 
of cases treated by caustics, which is certainly 
excellent. My own experience in the treatment 
of skin epithelioma by caustics has been very 
satisfactory. The anatomical facilities, however, 
for regional infection in the tissue around a 
mammary cancer are far greater than in the 
case of skin epithelioma, and the efficiency of 
caustics in the latter does uot imply their effi- 
ciency in the former class of growths. I shall 
therefore, for the present, adhere to the preva- 
lent practice of removing mammary cancer 
with the knife, cutting widely of the tumor. 
In dealing with recurrences, however, about 
the site of the disease, which usually occur in 
the skin along the line of the incision,,1 shall 
use caustics. 
The purpose of this paper is to show that in 
view of the exceedingly small, prospect of ef- 
fecting a cure by any operation when the dis- 19 
ease has extended beyond the tissues immedi- 
ately about the gland, and of the certainty of 
doing harm when a permanent cure is not ob- 
tained, that no operation is justifiable; but 
that in cases in which it is reasonable to believe 
the disease is limited to the gland, the minor 
operation should be be done, for if it is so lim- 
ited, the minor operation, properly done, will 
do all that can be done by the major with much 
less danger to the patient; and should the event 
show that the disease had not been thus lim- 
ited, it will not have accomplished less. 
The mind of the laity is deeply impressed 
with the belief that cancer of the breast is not 
cured by the knife, and victims of this disease, 
not knowing that the trouble comes rather from 
its abuse, naturally hesitate and delay when 
prompt action is of utmost importance; but I 
firmly believe that when surgeons shall have 
refrained from injudicious operating the time 
will soon come when these unfortunate women 
will fear delay and not the knife. Our records 
then will be far better. 
• Louisville.