Search

MY stand on the treatment of breast cancer has been widely misunderstood. Many surgeons believe that I advocate what the British call "lumpectomy" and irradiation. Nothing could be further from the truth. I do, however, stand firmly against the traditional radical mastectomy. I consider it to be archaic, and I believe that it has no place in the modern treatment of breast cancer.I strongly support modified radical mastectomy. It is primarily indicated for a patient who, at the time of operation, has palpable involvement of a few low or central axillary nodes. If the involvement is extensive, however, and particularly if the nodes at the apex are palpably involved, I agree with Haagenson that the axilla should not be dissected. It is better to rely on irradiation to control the cancer in the apical, supraclavicular, and internal mammary nodes.In patients who at the time of operation have no

• The results of conservative operations for breast cancer in 1,593 patients treated at the Cleveland Clinic between 1957 through 1975 are reported. During this period, we individualized our treatment of breast cancer depending on tumor size, location in the breast, and clinical stage of the disease. The following three principal operations were performed: modified radical mastectomy in 592 patients (37%), simple (total) mastectomy in 442 patients (28%), and partial (segmental) mastectomy in 291 patients (18%). Survival results at 5,10, and 15 years are reported. Factors important in long-term survival included stage of the disease, number of lymph node metastases, delay in therapy, size of the tumor, histologic type, and estrogen receptor status; type of operation was not a significant factor. In this series, partial (segmental) mastectomy without radiation therapy provided five- to 15-year survival rates equal to modified radical mastectomy and simple (total) mastectomy.(Arch Surg 1985;120:746-751)

The history of the evolution of thought about the treatment of breast cancer is reviewed. First the surgery was too radical, then radiation was overused; soon perhaps adjunctive chemotherapy will be overused. We should continue to search for new methods such as combinations of heat and radiation that might maintain or increase the immunologic resistance of the host.

Partial mastectomy without radiation therapy has been used at The Cleveland Clinic as a treatment option for selected patients with breast cancer since 1957. Our experience with 322 patients has been reviewed; survival results are equal to or better than the other operative procedures we have employed for the treatment of breast cancer. These results, we believe, relate more to the selection of patients with small tumors and at a more favorable stage of the disease than to the benefit of the operative procedure itself.

Thyroid needle biopsy has been used at the Cleveland Clinic since 1948 in more than 2,000 instances without serious complications. In the years 1979 and 1980, there were 481 needle biopsies performed, and the patients have been followed from 1 to 3 years. One hundred fourteen needle biopsies were with the 18-gauge needle, 119 were with the fine needle, and 248 were Tru-cut® biopsies. One hundred fourteen of the patients had 2 kinds of biopsies at the same time, usually Tru-cut® and fine needle. The Trucut® needle biopsy gave the highest percentage of success in obtaining diagnostic material with only a 4% failure in the hands of the surgeon using it most often. Aspiration with an 18-gauge needle and fixing the aspirate to form a cell block was found to be a safe and satisfactory way of obtaining material from cysts or nodules too small to be safely and easily sampled by a Tru-cut® technique. The fine-needle (ABC) biopsy is safe, simple, and economical and provides material sufficient to diagnose all types of thyroid cancer except the low-grade follicular type. This limits to some extent the usefulness of the ABC biopsy. Even with Tru-cut® core biopsies, it is often impossible to distinguish between cellular adenomas and low-grade adenocarcinomas. Since approximately one-third will prove to be malignant, surgery is adviced for these patients.

Though signal advances have been made recently in many surgical problems, the treatment of cancer of the head and neck has, it would seem, neither received the attention nor kept the pace of progress in other fields. These unhappy cases are too often regarded as specters at the clinic. The operative treatment is hampered by tradition and conventionality, and the tragic ending of so large a proportion of these cases has held back lay and even professional confidence.In this paper it is intended to present an outline sketch of the conclusions regarding the surgical treatment of cancer of the head and neck in the curable stage. The etiology, the diagnosis and the pathology will not be considered. It is generally admitted that cancer is primarily a local disease. Each case, then, is presumably at some period curable by complete excision.The immediate extension from the primary focus is principally

Since surgeons rarely write articles about simple minor operations that are easily performed in the office, there is a great reliance on techniques learned in medical school or from other surgeons. Some of these techniques are cumbersome and make relatively major procedures of operations that can be performed quite simply.

In 1923 Cowden1 was unable to find in the literature a report of hyperthyroidism in a boy under 10 years of age, but since that time several such reports have appeared. Helmholtz2 cited the case of a boy aged 3 years who had had symptoms of hyperthyroidism since the age of 11 months. The same author, in reporting 30 cases of exophthalmic goiter in children under 14 years of age, found that the incidence in boys was extremely low as compared with that in girls. In his series there were only 4 boys as compared with 26 girls.Elliot3 reported hyperthyroidism in a girl 2½ years old on whom an operation was performed at the age of 2 years and 10 months. After preliminary ligations, a right subtotal lobectomy was successfully performed, and the patient obtained complete relief from all symptoms. The onset of hyperthyroidism had been

The physiological basis for the use of vagotomy in the treatment of duodenal ulcer rests on two findings: (1) patients with duodenal ulcer have increased nocturnal gastric secretion of hydrochloric acid and (2) complete vagotomy abolishes the increased secretion.11 Excellent clinical results from the use of subdiaphragmatic vagotomy with gastroenterostomy in duodenal ulcer have been reported by Dragstedt, Crile, and others.2 An unpublished report of a nation-wide survey conducted by the vagotomy committee of the American Gastroenterological Association in 1950 cited excellent results from the operation in nearly 98% of the patients. Other reports have indicated an unsatisfactory experience with the operation, and the 1951 report of the committee mentioned above was less impressive than that of the preceding year, although there were still about 94% of patients satisfied with the results of the operation.3Because of these conflicting views, further studies on the long-term results of

The animals were all reduced to full surgical anesthesia by ether before the experiments were begun, and were killed before recovery therefrom. Respiratory tracings were obtained by means of a rubber tambour, attached to a canvas band, encirling three-fourths of the circumference of the animal's chest. This energized a writing style attached to an organ-key mechanism. Respiratory tracings were obtained very accurately. Blood-pressure was recorded by means of a mercury manometer. The drums were revolved by a mechanism so made as to be capable of a variety of movements, ranging from one revolution in thirty minutes to eighteen per minute, so that any phase of any given tracing might be duly recorded. The following is a part of a rather extended research, which enabled us to estimate the reliable reduction with comparatively few experiments.Surgeons have not infrequently encountered, in performing a laryngotomy, sudden collapse at the moment when the

In recent years the widespread publicity given to the subjects of cancer detection and prevention, the emphasis on periodic physical examinations and the development of cancer detection centers has resulted in an increased cancer consciousness in the population at large and in the medical profession. Therefore, physicians are being consulted oftener regarding the potential malignancy of benign lesions. Notable among these are nontoxic nodular goiters.Few physicians would deny that firm discrete adenomas of the thyroid should be removed. The controversial question is whether to advise removal of soft nontoxic nodular enlargements of the thyroid. Many of these goiters are not enlarging or causing symptoms, and the patients often are unaware of their presence until they are found on a routine physical examination. EXPLANATION OF THE HIGH REPORTED INCIDENCE OF CARCINOMA OF THE THYROID There

EFFECT ON PERIPHERAL NERVE TRUNKS. The injection of eucain or cocain into a nerve trunk so as to place all its structures in contact with the drug produces an effectual physiologic "block." By the word "block" is meant such condition of the nerve that neither afferent nor efferent impulses can pass, the conductivity being as completely interrupted as if the nerve were divided. While general anesthesia prevents the appreciation of pain and the production of voluntary motion, it does not prevent such other afferent impulses as those caused by mechanical, thermal or electrical stimulation of the nerve endings or trunks, which produce changes in the frequency and the amplitude of the respirations, in the frequency and force of the heart beats, and in vasomotor action. Either eucain or cocain injected into a nerve trunk as above described prevents the passing of such afferent impulses, thereby preventing effects upon the respiration,

The research a preliminary report of which is here presented was undertaken with the purpose of discovering some physical principle that might account for the conversion of normal cells into cancer cells, that is, into cells the energy of which is used only for growth, whereas the energy of the tissue in which the conversion takes place is used primarily for function. It is clear that the cancer cell must owe its formation to the operation of existing laws of growth in the host. These laws are most strikingly illustrated in the process of fertilization.The ovum and the sperm, as Keller has shown, exhibit opposite signs of charge, hence they attract each other. The preponderantly positive element exists apart from the preponderantly negative element, but when they unite growth and division take place, forming the beginning of a new organism. The fertilized ovum contains, therefore, elements bearing opposite signs

POSTCHOLECYSTECTOMY colic, or biliary dyskinesia, is a poorly defined syndrome which tends to occur in nervous and hypersensitive persons and which can be diagnosed only by the exclusion of organic disease. The cause of the dyskinesia has not been established, but it is supposed by some that spasm of the sphincter of Oddi plays a part in the production of the symptoms.1Biliary dyskinesia may cause symptoms indistinguishable from biliary colic due to a calculus. The patient complains of intermittent attacks of colicky pain in the right upper quadrant and epigastrium which may radiate to the scapula and to the right shoulder. Nausea and vomiting frequently are associated with the attacks. Chills, fever and jaundice do not ordinarily occur.The possibility of somatic pain as well as stone in the stump of the cystic duct, stone in the common duct, and disease of adjoining viscera (such as duodenal ulcer,

With the increased pace to which civilized man must adapt himself, there are several diseases accompanying his highly energized manner of living. Frequently the physician is called on to treat diabetes, peptic ulcer, essential hypertension, exophthalmic goiter, diseases of the coronary arteries and nervous and mental diseases. These conditions are exceedingly rare in primitive man and are uncommon in the lower ranks of civilized man. The more highly civilized man becomes, the more prevalent they seem to be.As man has become less concerned with fighting, hunting and other predominantly physical activities and more concerned with mental activities, the characteristic mental and emotional mechanism has continued to increase relatively in size and in dominance until there are now also increasing the diseases I have mentioned, which are in large part due to overactivity of the kinetic system. Evidence indicates that the kinetic system may, by its excessive activity, interfere with

THE THREE main and distinct clinical types of thyroiditis are (1) the subacute (pseudotuberculous or giant cell) variety, (2) struma lymphomatosa (Hashimoto's thyroiditis) and (3) Riedel's struma.1 Subacute thyroiditis resolves promptly and completely in response to roentgen therapy; some, and possibly most, cases of struma lymphomatosa respond favorably to roentgen rays, but Riedel's struma is unaffected by irradiation. SUBACUTE THYROIDITIS Subacute thyroiditis is a self-limited disease of unknown causation. It has a variable course of weeks or months and eventually subsides without treatment and without significant interference with the function of the thyroid.This type of thyroiditis has been variously named tuberculous, pseudotuberculous or giant cell thyroiditis because of the histologic appearance of pseudotubercles with giant cells. Tubercle bacilli cannot be demonstrated in the lesions, and the cause of the disease is unknown. Bacteria have not been demonstrated in the thyroid. The possibility that it represents a virus infection

The treatment of choice of wounds depends largely on the speed with which facilities adequate for definitive treatment can be made available. Surgeons may report excellent results in the treatment of civilian casualties in metropolitan hospitals using methods that would not be applicable to field conditions. When the wounded can be taken immediately to a well equipped hospital or to an undamaged sick bay aboard a capital ship, radical excision of wounds and other operations may be feasible and successful. But in jungle fighting, hours or days may elapse before the wounded reach a field hospital, which usually not only is crowded but is often subjected to air raids or even to artillery fire. Similarly, if the ship aboard which casualties occur is subsequently sunk, the wounded may float for hours before being rescued by a destroyer, whose sick bay may already be filled to overflowing and whose one medical

Lateral aberrant thyroid tumors occur as the result of an anomaly in the development of the thyroid gland. Histologically these tumors are not composed of normal thyroid tissue but have a papillary structure indistinguishable from that of papillary tumors of the thyroid.In forty-five of the 136 reported cases of tumors arising in lateral aberrant thyroid tissue, as shown in the accompanying table, the growth has been classified as malignant. Yet only two of the forty-five patients have been reported to have died as a result of recurrence of the tumor following operation. In no case has either local or distant metastasis of the tumor been proved. The remarkable survival record of the patients cannot fail to raise the question of whether or not the tumors were true carcinomas.Many of the tumors in the collected series were described as showing extensive metastasis to the cervical lymph nodes. Similarly it

A syndrome of profuse watery diarrhea, hypokalemia, and hypercalcemia, without gastric hypersecretion or ulcer is associated with pancreatic adenoma. Excision of a parathyroid adenoma and then hyperplastic parathyroid tissue temporarily relieved symptoms and restored serum calcium and serum potassium values to normal. The profuse watery diarrhea, hypercalcemia, and hypokalemia were permanently relieved by excision of a large pancreatic adenoma after recognition of the syndrome. The genetic aspects of this syndrome were demonstrated in the case presented. Of 14 members on the patient's paternal side, three had pancreatic adenomas, six had renal stones, and five had intractable peptic ulcers. Endocrine adenomas, frequently multiple, were seen in the patient and in two relatives.

THERE is a group of children and young adults who bleed frequently and severely from esophageal varices. These patients have normal livers and the varices are the result of a congenital block of the portal or splenic veins. If the bleeding could be controlled, these patients would return to perfect health and would have a normal life expectancy.Splenomegaly secondary to venous stasis is a constant finding in these cases, but it is rare that splenectomy permanently controls the tendency to bleed. Unfortunately, the majority of the patients have had their spleens removed, and after removal of the spleen it is not possible to use the splenic vein to effect a shunt between the portal and systemic veins.The young patient whose spleen has been removed cannot be helped by anastomosis of the portal vein to the vena cava. The block, in these cases, is either in the splenic vein proximal to the point of entry

CLEVELAND INTRODUCTIONThe species of animal now dominating the earth more completely than any other is at this moment in a state of abnormal activity — the back-wash of the European war is seen in the quickened pulse everywhere even in this land. Not only in war, but in peace also, the complicated machinery of civilization created by man often drives him to his own destruction. Nowhere is this industrial and commercial driving more intense than in this city. It has occurred to me, therefore, that it might be interesting to attempt an analysis of the mechanism by which this speeding is accomplished, and relate it to the speeding which is due to other stimuli such as infections, autointoxication, physical injury, etc. Since the process of speeding is identical with that of the transformation of potential into kinetic energy, the state of increased energy transformation might fittingly be called

The basis for this paper is a critical study of 472 operations on the stomach performed by my associates, Drs. Bunts and Lower, and myself, and in the records of Lakeside Hospital. Of these, 132 were performed by Dr. Lower and myself in accordance with the principle of anociation, these cases including explorations in cases of inoperable cancer, resections, and gastro-enterostomies for cancer and ulcer. Among these 132 cases there have been three deaths, a reduction from the former mortality rate in like cases of not less than 3:1. In but one other field is anociation so strikingly beneficial — in the surgical treatment of exophthalmic goiter.Originating in the great school of Vienna, fostered in Germany, its progress accelerated by Mayo-Robson, given a classic status by Moynihan, mechanized by Murphy, and culminating in the Mayo Clinic, the great field of gastric surgery through trial and error, progress and extension

For purposes of this paper, I shall divide surgical operations into two general classes: first, operations Performed on patients in fair fair general health; second; injury or disease. Belonging to the first class are: laparotomies for benign tumors of the uterus and ovaries,simple gastro-enterostomies, appendectomies, unoperations on patients whose vitality is impaired by complicated operations on the gall-bladder, the kidneys and the urinary bladder, uncomplicated herniotomies, excision of cancer of the breast, excision of benign tumors of thethyroid and simple goiters; in these the operative mortality has all but disappeared. Among 10,723 surgical operations performed by me, 4,127 belonged to this class; among these there was one death in 375 operations. There is but little advantage, therefore in any discussion of this group of cases so far as the immediate risk is concerned; but while the immediate risk is slight, these operations still bear a certain stigma, viz., a temporary nervous

Since the inauguration of the aseptic era the mortalityrate in abdominal operations has been falling steadily and to-day there are practically no deaths from simple abdominal operations for conditions unaccompanied by organic disease or infections.This reduced mortality-rate is due in part to an improvement in technic, but very largely to the exercise of an increasingly critical judgment on the part of the surgeon in his selection of cases.The technic has become standardized for such routine operations as the removal of benign tumors of the pelvic organs and for operations for chronic pyosalpinx, procidentia, prolapsus uteri, etc. The rare fatalities which occur in these apparently favorable cases result from some unforeseen and as yet uncontrollable factors such as embolism.The results secured by the individual surgeon have cometherefore to depend on two factors: his mastery of general operative technic and his policy in the selection of cases for operation.

To determine the limits of recovery after a total anemia of the central nervous system, a series of thirty dogs was killed by chloroform and resuscitated after varying times from three to fourteen minutes. Under five minutes the recovery of function was rapid and strikingly free from the after effects which characterized longer periods. Of seven animals between the periods of five and six and one-half minutes, only one died apparently as a direct result of the anemia, but of twelve between the periods of seven minutes and eight and one-half minutes, only one, after seven and one-half minutes recovered. The remaining dogs all died. Further corroborative data are drawn from the previously published paper on the technique of resuscitation. Histological examination both of presumptive recoveries and fatal cases was made by ordinary methods and those of Nissl and Marchi. The neurocytes of the fatal cases uniformly presented the greatest change, not merely chromolytic but here and there definitely indicative of cell death. Marchi's method further supported these findings by proving the existence of fiber degeneration. Finally, showing the narrowness of the escape, the animal with best result in recovery, seven and one-half minutes in time, which at the end of four weeks had apparently entirely returned to a normal state, by the Marchi method had a degeneration of a number of fibers localized in the pyramidal fasciculi which were traced from the cord to the cortex, and in Flechsig's fasciculus, as well as a more sparsely scattered degeneration of both ascending and descending fibers elsewhere.