Modern Surgical Technic III. [antikvár]

Surgery of the Breast "Simple mastectomy is too radical for a benign lesion and inadequate for cancer." (Bloodgood.) ORIENTATION In the last two or three decades no notable progress has been made in the diag-ncsis and treatment of carcinoma of the breast. True, refinement of technic and a better understanding of the problems involved have been achieved, but the over-all picture is still the same. Radical operation before metastases have occurred gives the best results. There is no unanimity of opinion as to the value of pre-and postoperative irradiation. The author has adopted the middle course and submits the patient to brief preoperative irradiation and postoperatively to a more intensive course of irradiation. When, after radiation therapy, nausea and vomiting occur, as is usual, this may be remedied by a high caloric diet, by decreasing the dose of irradiation or by interrupting therapy for a few days, if this seems necessary. In cases of advanced carcinoma of the breast, estrogenic substances in large doses have yielded gratifying results in some cases—in the relief of pain and the reduction of the size of the tumor. The author has seen bone lesions improve remarkably after hormone therapy. Dresser (1939) pointed out the value of roentgen ray sterilization in the treatment of bone metastases following carcinoma of the breast. Not all patients, however, are relieved by recourse to this type of therapy. In premenopausal patients bilateral mastectomy and oophorec- 1 tomy have yielded promising results (Guy W. Horsely). F. A. Adair^ has reported the successful use of testosterone propionate in approximately 200 cases of carcinoma of the female breast. Intramuscular injections of 100 mg. of testosterone propionate are given three times a week; a total dosage of 2,400 to 3,000 mg. Improvement is not to be anticipated when the tumor involves soft tissues such as liver, lungs and brain or when there is a local skin recurrence, but striking improvement is observed in most of the cases in which there is bone metastasis. Adair believes it probable that under the influence of testosterone the billions of cancer cells are "snowed under" by the copious deposit of calcium precipitates, especially in areas of bone destruction—a locking-in process in which cell reproduction is difficult. In cases of widespread bony metastases, the use of testosterone propionate seems to be more efficacious and longer lasting than x-ray therapy. Although to date most work has been done on cases of advanced malignancy of the breast, recently work has been started on cases of early operable carcinoma of the breast. Radical mastectomy is supplemented by large doses of testosterone implanted into the latissi-mus dorsi muscle or into the subcutaneous tissues near the wound at the time of the operation. This combination has been used by Adair in 135 cases to date. Two months after the operation further doses of testosterone are implanted. The patient receiving testosterone therapy usually develops some masculinizing sequelae, as evidenced by a deep, husky voice, hair on the face, acne on the face and body, and an enlarged 569