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THE LATE RESULTS OF BREAST SURGERY
507 the opportunities for adventure are no less. " Thou shalt love the Lord thy God with all thy heart an-d with all thy soul and with all thy strength " means to the student of science that he is to put all he is into his work, knowing that every attempt to understand the world he lives in is worth while. -LONDON:SATURDAY, SEPTEMBER 8, 1928. And if he writes Sirs, ye are brethren " as well, up, will help his fellows all the better.
industry
LANCET.
rr-HE
SCIENCE AND CRAFTSMANSHIP.
he
IN reflecting on the miserable conditions under which our primitive ancestors must have survived WxLLxnM JAMES has remarked somewhere that it is characteristic of man that he prefers life on any terms to no life at all. It is equally characteristic that he makes every effort to improve his circumstances, and if by craftsmanship we mean the skill which is exercised in the production of whatever is wanted for human welfare, then craftsmanship represents in a summary way man’s effort to live. Such is the meaning which Sir WILLIAM BRAGG puts .on the word in his presidential address delivered before the ninety-eighth meeting of the British Association for the Advancement of Science, which was opened at Glasgow on Wednesday, Sept. 5th. Prof. BRAGG has charmed many audiences at the Royal Institution with his explanations of and commentaries on the intimate relation between -modern scientific knowledge and the empirical practice of old artificers, and the burden of his present discourse is that scientific training and scientific method provide the craftsmanship of modern industry. There is a cult which exalts the beautiful and efficient implement made long ago by hand, singly and painfully, to a level which is wholly denied to the products of the machine tools and factories of to-day-a cult which often misleads itself by thinking that the average excellence of past production is fairly represented by the examples of old work which owing to their exceptional quality havesurvived for us to see
"
THE LATE RESULTS OF BREAST SURGERY. Now that operation as the method of choice in treating cancer of the breast is being seriously challenged by the supporters of radium therapy, Dr.
JANET LANE-CLAYPON’s survey 1 of the late results of various kinds of operation for growths at different stages is opportune. She has here freed the literature of breast surgery from the reproach, exposed by her previous analysis (No. 33 of the same series of grey books), that most of the statistics published are based on a follow-up after operation of only three years, which period she found to be the average duration of life in untreated cases. Surgeons will be gratified, if hardly surprised, to learn that on the whole the impressions derived from short periods of observation are confirmed ; the lasting success of the Halsted technique or one of its modifications depends almost entirely on the stage of disease at which it is perThe basis adopted by Dr. LANE-CLAYPON formed. for calculating results is that of the net survival rate-that is, the proportion of survivors to those operated upon, after deducting entirely from the sample those not traced and also those certified as having died from causes other than cancer. Early cases, where the primary growth was undoubtedly malignant but microscopical examination showed no invasion of cancer glands (Group IP.) show the remarkably high survival-rate, ten years after operation, of 73’3 per cent. This rate includes partial operations, - and use. and rises to 77-2 if only tho3e case3 submitted to With such a point of view the President of the radical operation are included. In many other British Association has very little sympathy ; he such as the mean lowered fertility respects .sees that the mass conditions of to-day demand for in the history, delay in seeking treatment, and the success just that same combination of imagination, functional results after removal of the pectoral good intelligence, and manipulative skill which was needed muscles-the commonly accepted teaching is also when man was groping his way through the early confirmed. It is profitable, however, to examine stages of the development of what SAMUEL BuTLER this exhaustive study in order to ascertain in what so aptly calls detachable limbs. Conditions have respects the conclusions reached differ from those changed because what is knowable has outgrown the generally held. The lessons that the clinician may capacity of one human mind to know, and specialisa- learn through the massed results from eight importion has come in with, as always, some tendency to tant county boroughs are noteworthy. disintegration. The intelligence and imagination of Broadly speaking, it seems tLat the clinical criteria modern production are now largely derived from of of a primary growth are reliable and malignancy those who pursue natural knowledge, and progress need no revision. At least this is the deduction to in invention depends on the progress of science and be drawn from the direct evidence afforded by 364 the degree to which use is made of its discoveries in cases where the was not confirmed by a diagnosis the practical world. LEONARDO or REAUMUR are pathological report on the primary growth. The ’impossible to-day, but there is no reason why science results following operation on these cases have been and technology should not achieve equal triumphs if considered separately and have been if anything they can cooperate with such free friendliness as takes slightly worse than those of the confirmed cases. no count of status or credit, if only the common good Indirect evidence, on which Dr. LANE - CLAYPON is achieved. Empiricism is not the prerogative of lays considerable stress in a closely written argument technology, nor coherent knowledge of natural (Chapter 13), is less flattering to the clinician. Among science. The wave theory of light is good because, the total number of cases in the survey there were in some relations, it works ; the electrical theory is 380 in which the of the primary growth malignancy -also good because it also, in other relations, works. was established histologically, though neither pathoAnd no one so far has had the wit to see how the two nor clinician could find any trace of invasion logist -theories may be reconciled. That such a state of of the axillary glands ; 370 of these were classified affairs should prevail in the branch of natural know1 Reports on Medical subjects, No. 51. Report on the Late ledge which has made the most notable progress in Results of Operation for Cancer of the Breast, being an Analysis the last 50 years testifies alike to the common of 2006 Cases occurring in the Practice of the General Hospitals Eight County Boroughs of England and Wales during the humanity of science and to the field which it offers of period 1910-1921. London, 1928, Ministry of Health, H.M. In its applications to Stationery Office. Pp. 143. 3s. ior intellectual adventure. "
"
-
508 in a table according to the operation performed, obvious that at an early stage of invasion thesenine being discarded because the exact technique glands are not palpable. In Chapter 6 of her report used was not recorded, and one for no stated Dr. LANE-CLAYPON shows that while positive findings. reason. The five operating methods used were: are for the most part confirmed by histological 1 (244 cases), radical operation ; 2 (45 cases), ’, examination, palpation is quite unreliable as a method two operations-that is, removal of tumour or I of assessing the condition of these glands. Of the breast for pathological report, followed by radical 169 cases in which examination at the bedside gave operation at a later date ; 3 (28 cases), removal of negative results, 90-or 53 per cent.-were incorrect. the breast, together with such of the axillary contents The import of this grave error is best seen in regard. to the selection of operation. The third method in as could be taken without removing the pectorals ; 4 (18 cases), amputation of breast only; 5 (35 Dr. LANE-CLAYPON’S list consists of removal of the cases), removal of tumour only. Dr. LANE-CLAYPON breast together with such of the axillary contents gives her reasons for considering that where methods as can be taken without removing the pectorals, and 2, 4, and 5 were chosen-that is, in 98 cases-there has evidently been chosen by the surgeon in the. must have been an original error in clinical diagnosis. mistaken hope of saving from the radical operationIn none of them is there a note of either a preliminary those patients in whom the axillary glands are deemed incision or a frozen section, and in several instances to be normal. The fate of patients operated on by the first operation was performed in the out-patient this method is, as Dr. LANE-CLAYPON puts it, surprising, department or by the patient’s own doctor. From and very deplorable, being much worse than that these and other considerations she assumes that the of those in whom either breast or tumour only was practitioners were reasonably satisfied as to the removed. The survival-rate after method 3 in the, innocence of the growth. In one of the 45 cases group of cases showing no. clinical evidence of’ where method 2 was used, duct papilloma had in fact invaded axillary glands is lower at all periods been recorded, in another chronic mastitis, while 11, after operation even than the rate of the advanced diagnosed as suffering from cysts, had in fact group where the glands were definitely palpable. cysts, with small foci of cancer cells in the wall There is, moreover, reason to believe that the cases. or in an intracystic papilloma,. Incidentally, these operated on by method 3, far from being advanced, cases provide instructive examples of the differenti were considered to be so doubtfully malignant as to, microscopical appearance to be found in different be suitable for a conservative operation. The conparts of the same breast, to which Sir LENTHAL clusion reached is that the terrible results are due CHEATLE has drawn attention, and support his con- to the rapid spread of the growth following incision tention that a pathological report confined to the into axillary tissue which contained undetected obvious tumour may be highly misleading. Statisti- I cancer cells, and that this operation should never cally, the method of two operations gives results nearly be performed. Evidence that clinical palpation of as good as does radical operation at one sitting, but the axillary glands is not reliable has another bearing since a second operation is sometimes refused and not mentioned in the report. Some surgeons of the-much distress of mind often occasioned, it is recom- younger school are inclined to despair of the possibility mended that in all cases tumours should be removed of eradicating the disease if the axillary glands areunder such conditions that the surgeon can proceed already palpable, and are inclined to remove theat once to the larger operation if he thinks it desirable. breast only as a palliative measure. We call their Leaving for the moment consideration of method 3, we attention to the fact that positive results of axillary note that pathological reports on the 53 cases in which palpation, though more accurate than negativeones,. methods 4 and 5 were used indicate that the growth was are too pessimistic in 17 per cent. of cases, and that very early. In 20 of them the clinical diagnosis was the survival-rate after ten years, even of the group’ definitely that of an innocent condition, and it may where glands are easily palpable, is by no meansbe assumed that no surgeon would do such a very negligible if radical operation is performed. limited operation in the face of a suspicion of cancer. The data supplied in this report does not show the converse side of the picture-how many persons have COLLAPSE THERAPY IN PULMONARY had a radical operation for a benign growth. This TUBERCLE. may be relatively unimportant to those chiefly NEARLY half a century has elapsed since the first concerned with the public health, but the practitioner experiments in collapse therapy were made,, considering drastic operation for a doubtful tumour tentative but it is only in the last 25 years that the method An ask the educated question. might pertinently has been generally employed. In that period the patient who has been persuaded to have breast and treatment of pulmonary tuberculosis by artificial pectoral muscles removed may await the pathologist’s pneumothorax has saved more lives than all the other> report with keen apprehension, but her relief when methods of treatment added together. By its means, she hears that her tumour was a benign growth may those who would formerly have been regarded as. well react on her faith in her medical adviser, especially incurable have regained health, and the dying have if hers is one of the rare cases where the functional been restored to life. Time, which has seen the rising results are indifferent. It is possible, too, that when and setting of innumerable " cures," has only estabmore firmly the value of pneumothorax. women are trained to report any swelling of the breast lished to their doctors immediately they notice it, the diffi- Unhappily, only a minority of the afflicted can benefit by this method of treatment. Those suffering from. culty of clinical diagnosis will be greatly enhanced bilateral disease may obtain a measure of relief from since the chief criteria of malignancy with which artificial pneumothorax, but in their case only every student is familiar may not be apparent in temporary benefit can, as a rule, be expected, whilereally early cases. This is a bogy that need not yet probably more than half of the unilateral cases are cause alarm, for, unfortunately, the doctor rarely sees unsuitable on account of adhesions which bind the the disease at its inception, and the malignant nature lung to the chest wall and prevent efficient collapse.of a primary growth is probably diagnosed more The greatest triumphs of collapse therapy have been obtained in the case of patients in whom the disease successfully in the breast than in any other situation. is limited to one lung and in whom the pleura is free. The clinical estimation of the invasion of axillary If these conditions are present, complete and lasting glands is, apparently, far less satisfactory, and it is cure may be anticipated in a proportion of cases.
I I
’,
industry
LANCET.
rr-HE
SCIENCE AND CRAFTSMANSHIP.
he
IN reflecting on the miserable conditions under which our primitive ancestors must have survived WxLLxnM JAMES has remarked somewhere that it is characteristic of man that he prefers life on any terms to no life at all. It is equally characteristic that he makes every effort to improve his circumstances, and if by craftsmanship we mean the skill which is exercised in the production of whatever is wanted for human welfare, then craftsmanship represents in a summary way man’s effort to live. Such is the meaning which Sir WILLIAM BRAGG puts .on the word in his presidential address delivered before the ninety-eighth meeting of the British Association for the Advancement of Science, which was opened at Glasgow on Wednesday, Sept. 5th. Prof. BRAGG has charmed many audiences at the Royal Institution with his explanations of and commentaries on the intimate relation between -modern scientific knowledge and the empirical practice of old artificers, and the burden of his present discourse is that scientific training and scientific method provide the craftsmanship of modern industry. There is a cult which exalts the beautiful and efficient implement made long ago by hand, singly and painfully, to a level which is wholly denied to the products of the machine tools and factories of to-day-a cult which often misleads itself by thinking that the average excellence of past production is fairly represented by the examples of old work which owing to their exceptional quality havesurvived for us to see
"
THE LATE RESULTS OF BREAST SURGERY. Now that operation as the method of choice in treating cancer of the breast is being seriously challenged by the supporters of radium therapy, Dr.
JANET LANE-CLAYPON’s survey 1 of the late results of various kinds of operation for growths at different stages is opportune. She has here freed the literature of breast surgery from the reproach, exposed by her previous analysis (No. 33 of the same series of grey books), that most of the statistics published are based on a follow-up after operation of only three years, which period she found to be the average duration of life in untreated cases. Surgeons will be gratified, if hardly surprised, to learn that on the whole the impressions derived from short periods of observation are confirmed ; the lasting success of the Halsted technique or one of its modifications depends almost entirely on the stage of disease at which it is perThe basis adopted by Dr. LANE-CLAYPON formed. for calculating results is that of the net survival rate-that is, the proportion of survivors to those operated upon, after deducting entirely from the sample those not traced and also those certified as having died from causes other than cancer. Early cases, where the primary growth was undoubtedly malignant but microscopical examination showed no invasion of cancer glands (Group IP.) show the remarkably high survival-rate, ten years after operation, of 73’3 per cent. This rate includes partial operations, - and use. and rises to 77-2 if only tho3e case3 submitted to With such a point of view the President of the radical operation are included. In many other British Association has very little sympathy ; he such as the mean lowered fertility respects .sees that the mass conditions of to-day demand for in the history, delay in seeking treatment, and the success just that same combination of imagination, functional results after removal of the pectoral good intelligence, and manipulative skill which was needed muscles-the commonly accepted teaching is also when man was groping his way through the early confirmed. It is profitable, however, to examine stages of the development of what SAMUEL BuTLER this exhaustive study in order to ascertain in what so aptly calls detachable limbs. Conditions have respects the conclusions reached differ from those changed because what is knowable has outgrown the generally held. The lessons that the clinician may capacity of one human mind to know, and specialisa- learn through the massed results from eight importion has come in with, as always, some tendency to tant county boroughs are noteworthy. disintegration. The intelligence and imagination of Broadly speaking, it seems tLat the clinical criteria modern production are now largely derived from of of a primary growth are reliable and malignancy those who pursue natural knowledge, and progress need no revision. At least this is the deduction to in invention depends on the progress of science and be drawn from the direct evidence afforded by 364 the degree to which use is made of its discoveries in cases where the was not confirmed by a diagnosis the practical world. LEONARDO or REAUMUR are pathological report on the primary growth. The ’impossible to-day, but there is no reason why science results following operation on these cases have been and technology should not achieve equal triumphs if considered separately and have been if anything they can cooperate with such free friendliness as takes slightly worse than those of the confirmed cases. no count of status or credit, if only the common good Indirect evidence, on which Dr. LANE - CLAYPON is achieved. Empiricism is not the prerogative of lays considerable stress in a closely written argument technology, nor coherent knowledge of natural (Chapter 13), is less flattering to the clinician. Among science. The wave theory of light is good because, the total number of cases in the survey there were in some relations, it works ; the electrical theory is 380 in which the of the primary growth malignancy -also good because it also, in other relations, works. was established histologically, though neither pathoAnd no one so far has had the wit to see how the two nor clinician could find any trace of invasion logist -theories may be reconciled. That such a state of of the axillary glands ; 370 of these were classified affairs should prevail in the branch of natural know1 Reports on Medical subjects, No. 51. Report on the Late ledge which has made the most notable progress in Results of Operation for Cancer of the Breast, being an Analysis the last 50 years testifies alike to the common of 2006 Cases occurring in the Practice of the General Hospitals Eight County Boroughs of England and Wales during the humanity of science and to the field which it offers of period 1910-1921. London, 1928, Ministry of Health, H.M. In its applications to Stationery Office. Pp. 143. 3s. ior intellectual adventure. "
"
-
508 in a table according to the operation performed, obvious that at an early stage of invasion thesenine being discarded because the exact technique glands are not palpable. In Chapter 6 of her report used was not recorded, and one for no stated Dr. LANE-CLAYPON shows that while positive findings. reason. The five operating methods used were: are for the most part confirmed by histological 1 (244 cases), radical operation ; 2 (45 cases), ’, examination, palpation is quite unreliable as a method two operations-that is, removal of tumour or I of assessing the condition of these glands. Of the breast for pathological report, followed by radical 169 cases in which examination at the bedside gave operation at a later date ; 3 (28 cases), removal of negative results, 90-or 53 per cent.-were incorrect. the breast, together with such of the axillary contents The import of this grave error is best seen in regard. to the selection of operation. The third method in as could be taken without removing the pectorals ; 4 (18 cases), amputation of breast only; 5 (35 Dr. LANE-CLAYPON’S list consists of removal of the cases), removal of tumour only. Dr. LANE-CLAYPON breast together with such of the axillary contents gives her reasons for considering that where methods as can be taken without removing the pectorals, and 2, 4, and 5 were chosen-that is, in 98 cases-there has evidently been chosen by the surgeon in the. must have been an original error in clinical diagnosis. mistaken hope of saving from the radical operationIn none of them is there a note of either a preliminary those patients in whom the axillary glands are deemed incision or a frozen section, and in several instances to be normal. The fate of patients operated on by the first operation was performed in the out-patient this method is, as Dr. LANE-CLAYPON puts it, surprising, department or by the patient’s own doctor. From and very deplorable, being much worse than that these and other considerations she assumes that the of those in whom either breast or tumour only was practitioners were reasonably satisfied as to the removed. The survival-rate after method 3 in the, innocence of the growth. In one of the 45 cases group of cases showing no. clinical evidence of’ where method 2 was used, duct papilloma had in fact invaded axillary glands is lower at all periods been recorded, in another chronic mastitis, while 11, after operation even than the rate of the advanced diagnosed as suffering from cysts, had in fact group where the glands were definitely palpable. cysts, with small foci of cancer cells in the wall There is, moreover, reason to believe that the cases. or in an intracystic papilloma,. Incidentally, these operated on by method 3, far from being advanced, cases provide instructive examples of the differenti were considered to be so doubtfully malignant as to, microscopical appearance to be found in different be suitable for a conservative operation. The conparts of the same breast, to which Sir LENTHAL clusion reached is that the terrible results are due CHEATLE has drawn attention, and support his con- to the rapid spread of the growth following incision tention that a pathological report confined to the into axillary tissue which contained undetected obvious tumour may be highly misleading. Statisti- I cancer cells, and that this operation should never cally, the method of two operations gives results nearly be performed. Evidence that clinical palpation of as good as does radical operation at one sitting, but the axillary glands is not reliable has another bearing since a second operation is sometimes refused and not mentioned in the report. Some surgeons of the-much distress of mind often occasioned, it is recom- younger school are inclined to despair of the possibility mended that in all cases tumours should be removed of eradicating the disease if the axillary glands areunder such conditions that the surgeon can proceed already palpable, and are inclined to remove theat once to the larger operation if he thinks it desirable. breast only as a palliative measure. We call their Leaving for the moment consideration of method 3, we attention to the fact that positive results of axillary note that pathological reports on the 53 cases in which palpation, though more accurate than negativeones,. methods 4 and 5 were used indicate that the growth was are too pessimistic in 17 per cent. of cases, and that very early. In 20 of them the clinical diagnosis was the survival-rate after ten years, even of the group’ definitely that of an innocent condition, and it may where glands are easily palpable, is by no meansbe assumed that no surgeon would do such a very negligible if radical operation is performed. limited operation in the face of a suspicion of cancer. The data supplied in this report does not show the converse side of the picture-how many persons have COLLAPSE THERAPY IN PULMONARY had a radical operation for a benign growth. This TUBERCLE. may be relatively unimportant to those chiefly NEARLY half a century has elapsed since the first concerned with the public health, but the practitioner experiments in collapse therapy were made,, considering drastic operation for a doubtful tumour tentative but it is only in the last 25 years that the method An ask the educated question. might pertinently has been generally employed. In that period the patient who has been persuaded to have breast and treatment of pulmonary tuberculosis by artificial pectoral muscles removed may await the pathologist’s pneumothorax has saved more lives than all the other> report with keen apprehension, but her relief when methods of treatment added together. By its means, she hears that her tumour was a benign growth may those who would formerly have been regarded as. well react on her faith in her medical adviser, especially incurable have regained health, and the dying have if hers is one of the rare cases where the functional been restored to life. Time, which has seen the rising results are indifferent. It is possible, too, that when and setting of innumerable " cures," has only estabmore firmly the value of pneumothorax. women are trained to report any swelling of the breast lished to their doctors immediately they notice it, the diffi- Unhappily, only a minority of the afflicted can benefit by this method of treatment. Those suffering from. culty of clinical diagnosis will be greatly enhanced bilateral disease may obtain a measure of relief from since the chief criteria of malignancy with which artificial pneumothorax, but in their case only every student is familiar may not be apparent in temporary benefit can, as a rule, be expected, whilereally early cases. This is a bogy that need not yet probably more than half of the unilateral cases are cause alarm, for, unfortunately, the doctor rarely sees unsuitable on account of adhesions which bind the the disease at its inception, and the malignant nature lung to the chest wall and prevent efficient collapse.of a primary growth is probably diagnosed more The greatest triumphs of collapse therapy have been obtained in the case of patients in whom the disease successfully in the breast than in any other situation. is limited to one lung and in whom the pleura is free. The clinical estimation of the invasion of axillary If these conditions are present, complete and lasting glands is, apparently, far less satisfactory, and it is cure may be anticipated in a proportion of cases.
I I
’,