ture in the arterial coats being the result of the "passage" of the muscle from "rest into action"—a condition of electrical "discharge." Perfectly normal hearts were thus stimulated, as well as those suffering from depression. But in all cases where there was great muscular depression, no stimulation resulted, but rather a further depression. From which it can readily be seen that the heart of convalescence, from the diseases mentioned in the paper, would not be benefited by electricity. But the case here reported improved by its use to a great degree. If the exciting poison had produced great muscular change, the electricity would have done harm instead of good. But believing that the heart of diphtheritic paralysis was not one of primary muscular change, the electrical stimulation was used early in the treatment of the case with the results already mentioned. In studying the history of this particular case, I have no doubt that the continuous current would have produced similar results. But the faradic was used at the commencement of the treatment, and for the sake of uniformity its use was continued throughout.

An important question may here be asked. Are there any special or particular lines of treatment which will aid in preventing the paralysis?

Diphtheritic paralysis, then, is a disease of the utmost gravity. It has a certain anatomical lesion, the manifestations of which the neurologists are beginning to recognize, and the nature of which they are commencing to investigate. That such is the case we have had in this room, only a few meetings since, testimony of the highest possible value, in the paper on the "Pathological Processes in the Nervous System," presented by Dr. Landon Carter Gray, in which the author mentioned, quite incidentally, it is true, but still in which he mentioned the changes produced in the nervous system by what he termed the diphtheritic

virus.

SOME EXPERIENCES IN THE OPERATIVE TREATMENT OF CARCINOMA OF THE BREAST.

BY GEO. RYERSON FOWLER, M D.,

Surgeon to St. Mary's and the Methodist Episcopal Hospital, Brooklyn, N. Y.

Read before the Brooklyn Surgical Society, January 19, 1890.

During an experience of nearly nineteen years of surgical practice there have come under my observation upward of 100 cases of carcinoma of the breast, the histories of 64 of which are more or less complete. Of these no less than 10 have presented themselves to me with the

disease so far advanced that operative interference was considered unjustifiable. Of the inoperable cases, I was a case in which the disease had extended to the pleura; 6 involved the chest-wall, extending to the supra-clavicular region and involving the pectoralis major muscle, as well as its underlying lymphatic glands; while 3 were refused operation because of the advanced cachexia, and exhausted condition from extensive u ceration, prolonged discharge and frequent hæmorrhage. Of the 6 cases, in which extensive involvement of the chest-wall existed, 2 were denied the advantages of even the slight chance which interference might offer by the occurrence of secondary deposits in or coexistence of carcinoma of the abdominal viscera. In one of these, carcinoma of the stomach was reasonably certain to be present; in another, hepatic carcinoma was suspected; and in a third case, pleural and pneumonic involvement was present. The case of so-called metastasis to the lung and pleura coexisted with extensive involvement of the chest-wall; it is more than probable that the intra-thoracic structures were attacked by direct infection through neighborhood rather than a true metastasis. It is a sad commentary upon the intelligence of the practitioners under whose care 4 of these 10 cases came that the patients were informed by their medical attendant that the growth was of an innocent character and would never give rise to any inconvenience. Relying upon this, one of these fell a victim to intrathoracic cancer, and the remaining 3 to advanced cachexia, hæmorrhage, and consequent exhaustion. Upon the patients themselves, in 6 cases, rested the responsibility of a failure to appreciate the gravity of the situation, inasmuch as 4 failed to seek advice until the disease was far advanced, and the remaining 2 refused to credit the statement of their attendants that their malady was of so serious a character.

Of these 64 cases, all were females. I have never met with cancer of the breast in a male. The average age is shown by my notes to have been 51.4 years, the youngest being 22 and the oldest 67.

The cases were distributed, as regards the periods of life, as follows: 23 occurred during the period of active menstruation or child-bearing, from the 22d to the 45th year; 27 occurred during the climacteric, from 45 to 55; during the period of extinguished sexual life, after the 55th year, 15 were noted.

Deducting the 10 cases considered inoperable, of the remaining 54, 6 declined operation. The number still remaining and operated upon leaves the average age about the same as that of the entire number observed, viz., 51 years and 6 months.

Of the total number observed but 3 were unmarried women, and of these I have reason to believe that 2 were virgins. Perhaps the third one should be classed among those whose sexual organs had undergone

the changes incident to the married condition. She confessed to at least two abortions, prior to the third month of pregnancy, although she declared that she had never borne a living child 40 had borne children; the histories of 30 show that of these, 19 had borne 5 or more children and II had borne more than two. This last does not include one case in which but one conception took place, the result being twins. Of the remaining 24 noted as not having borne living children, 18 had had one or more abortions, while the remaining 6 were sterile. Of 30 who had borne children, 21 had nursed them at the breast; 16 had nursed more than five children. Of the 9 classified among those who had not nursed their children, 3 had failed to do so from choice, while 4 attempted to do so but were prevented in 3 cases by the occurrence of fissured nipples; of the remaining 2 cases, in one the physiological activity of both glands remained latent through three pregnancies, and in the other a double mastitis after the first labor prevented lactation; the patient shortly thereafter became a widow and remained so up to the time of coming under observation.

Of the 30 histories, in 2 the patients had been compelled to nurse their children from but one breast. The reason assigned, in both instances, was the occurrence of acute suppurative mastitis in the same breast, in four consecutive pregnancies in one instance, and in three in the other, the remaining breast being depended upon solely to nurse the subsequent children. In both of these cases the breast which had undergone the greatest functional activity-i. e., the breast from which all the children were nursed-was the one attacked by the disease.

13 of the number of cases coming under observation, or more than one-fifth, gave a distinct history of acute inflammatory conditions in the breast preceding the disease; 43 gave a history of fissured nipples. The length of time intervening between the occurrence of mastitis and the development of the carcinomatous nodule, in 20 cases, varied from II months to 28 years. In 8 cases out of the entire number (64) the patients attributed the occurrence of the disease to the infliction of traumatism, and in 3 a history of injury was elicited by questioning upon this point. In all of these cases the disease made its appearance within a year following the injury.

Pagat's eczema of the nipple preceded the appearance of the nodule in 2 cases, the period of time intervening between the eczema and the carcinoma being four and eighteen months respectively. One of these cases occurred in an unmarried woman, and the other in a woman who had nursed three children.

In 10 cases a distinct history of heredity was obtained. In 2 cases nothing could be learned of the family history. In the remaining cases the result of inquiry upon this point was distinctly negative.

The

The two breasts were attacked with about equal frequency. upper and outer segment of the breast was found to be the site of the disease in 30 of the 50 cases in which this point was noted.

Retraction of the nipple or dimpling of the skin overlying the nodule, showing decided involvement of the super-adjacent structures, was observed in 16 out of 30 cases. The period of time intervening between the noticeable appearance of the disease in these cases and the skin involvement, at the earliest was eight months and at the latest three and a half years.

Ulceration of the integument had occurred in 14 of the 64 cases; 10 of these were deemed inoperable. The earliest occurrence of ulceration in 30 cases was ten months following the discovery of the nodule; the latest one and a half years.

In 34 of the 60 cases, axillary lymphatic infection was made out. These included the 10 inoperable cases. Of the 45 cases operated upon, 3 were found upon opening up along the line of the pectoralis muscle and into the axilla, to trace lymphatic glandular involvement not before suspected or made out. The time elapsing between the discovery of the existence of the disease and the demonstrable lymphatic induration varied from six and a half months to a year. Dividing the gland into two lateral halves by an imaginary line drawn vertically through the nipple, in the 30 cases above referred to, it was found that, on an average, the lymphatic involvement occurred about three and a half months earlier where the tumor occupied the outer half of the gland. No definite importance could be attached to the occurrence of the growth in the upper as compared with the lower half of this segment of the gland, in its relation to axillary infection. Immobility, to a greater or less extent, or rather a lessened mobility as compared to the other breast, was observed in 13 out of the 20 operated cases in which lymphatic infection was demonstrated prior to operation; 4 other operated cases likewise presented this objective symptom, comparative immobility of the breast without demonstrable axillary lymphatic infection existing.

In the 45 cases in which operative interference was carried out, the method of procedure invariably consisted in typical amputation of the breast. In 36 of the series, opening up along the line of the pectoral muscle and into the axilla was added to the amputation, constituting what may be called the complete operation. In one case-not included in this study because of the fact that too short a time has elapsed since the operation to consider its history as complete-the axillary artery and vein were both involved in the diseased lymphatic glands, and two and a half inches of these vessels were removed with the mass. In another case the artery was accidentally wounded, and simultaneous

ligature of the artery and vein practised. No untoward disturbance occurred as a result of this in either case.

In clearing out the axilla, every trace of lymphatic glandular tissue accessible and capable of identification was removed, whether apparently involved in the disease or not. In the entire number operated upon but a single case was observed in which the supra-clavicular fossa was invaded by the disease. The infra-clavicular space was attacked in 4 cases In 10 of the cases operated upon in my earlier experience, the axilla was opened up and cleared, because of the palpable existence of glandular infiltration. In 5 of the 36 cases in which the complete operation was performed, the edge of the pectoral muscle was found to be involved in the disease and removed. In these latter cases the average time, from the commencement of the symptoms until the time of operation, was eleven and a half months.

As to the immediate results of the operation in no case was a fatal issue clearly traceable to the interference.

Of 29 of the patients whose histories have been traced up to the 3d year, operations for recurrence have been performed in 5 instances. In addition to these, 2 cases have come under my care, of recurrence, which had been operated upon by other surgeons. Of these 7 cases, 6 had not had the axilla cleared; and of the 5 operated upon by myself, and whose early condition I am familiar with, 4 had retraction of the nipple or other evidences of the involvement of the skin, as well as some degree of fixation of the gland to the underlying structures. The average time of recurrence was a fraction less than eight months. The latest recurrence in those coming under notice for operation the second time was one year and eight months, and the earliest was three months. Of the entire 29 cases, with complete histories (and no case occurring during the last two years is here included), 4 are known to be still living with no evidence of recurrence; three, four, five and a half, and ten years have elapsed respectively in these cases. In but I of these (the one now three years old) was clearing of the axilla omitted. In the one four years old, the gland was almost immovable upon the underlying structures, and portions of the muscular structures as well as the pectoral fascia were dissected away. In the case now five and a half years old, a local recurrence took place at the end of three months, which was promptly removed. Of the other 4 cases operated upon for recurrence, 2 are known to have since perished from the disease, and the remaining 2 I have been unable to trace.

If the cases not operated upon and of which I have knowledge be added to the inoperable cases, 15 cases may be said to have pursued an uninterrupted course to a fatal termination. The average length of time which these patients lived after the outset of the disease was a year