SINCEHalsted described his technique of radical operation for cancer of the breast in 1907 there has been little significant improvement in the prognosis of this disease. This mood of complacency is not borne out by even the best figures. It is well to reflect that an 80 per cent 5-year survival in early cancer means that 20 out of every IOO women were probably beyond the stage of routine operative measures, even though the pathological report showed no spread to the axillary lymph-glands. Endeavouring to improve these results Urban (1964) has advocated a supra-radical mastectomy with en bloc resection of one-third of the sternum, the costal cartilages, and underlying lymph-nodes and parietal pleura, in addition to the conventional radical mastectomy.Dahl-Iversen and Tobiassen (1963) combined radical mastectomy with supraclavicular and parasternal dissection, and Haagensen and Cooley (1963)~ in an attempt to select only operable cases for radical mastectomy, have described a method of determining the extent of the disease by means of what they call a triple biopsy. These extended operations have not found favour in England and in the less experienced hands of general surgeons would undoubtedly lead to increased morbidity and operative mortality. Indeed, some surgeons who have advocated these extended procedures have now realized that their results were no better than with radical mastectomy (Cutler, 1965). For perhaps too long a time adjuvant radiotherapy was held to be the answer.When Paterson (1962) published his figures it became clear that radiotherapy following radical mastectomy showed no statistical difference in the crude mortality rate at 5 or 7 years between those so treated and those who were only carefully watched, and that in the long run it was better to withhold radiotherapy until secondary deposits develop. McWhirter (1955) advocates simple mastectomy and radiotherapy, and his initial results appear to be as good as those with radical mastectomy. Unfortunately other centres have not been able to reproduce his figures. It is therefore clear that radical mastectomy has stood the test of time as the best available treatment for operable cancer of the breast. The effect of cytotoxic drugs and hormones in prolonging life in the advanced cases of cancer is well known. Their real value must surely lie in their use in early operable cases. It seems reasonable therefore that their addition to operation is a logical procedure.This communication reports our experience with 62 cases of operable breast cancer treated by radical mastectomy with intra-arterial perfusion of cyclophosphamide. SELECTION AND PREPARATIONOF PATIENTS Only cases of clinical Stage I and Stage I1 breast cancers, i.e., clinically operable cases, are included in this series.Prior to operation haemoglobin, white-cell count, reticulocyte count, platelet count, and liver-function tests are carried out in addition to chest radiographs and routine skeletal screening. In our early cases IOO mg. of cyclophosphamide were administered orally a day b...
Published accounts of mitral valvotomy have come from hospital departments specially experienced in thoracic surgery and with resources much above the ordinary. Their eminent authors have contributed to the pioneer work and development of this brilliant advance in surgery and medicine. Conscious of the comparison and of our few cases, we explain that the purpose of this paper is simply to indicate that the selection of cases and the operation itself are now a well-established procedure within the competence of a general physician and surgeon interested in the subject. At the time we decided to do this work candidates for the operation were sent away far from home, there was a long waiting-list, and it had been reported (British Medical Journal, 1950) that patients had died in acute pulmonary oedema while waiting.The better interpretation of clinical findings resulting from the work to which we have already referred enabled us to make more accurate pre-operative diagnoses and to manage without cardiac catheterization. Latterly the operation was done in the ordinary theatre list, electrocardiograms were no longer taken during the operation, and we dispensed with the post-operative oxygen tent; oxygen, if required, was given by means of Tudor Edwards's spectacles frame. The approach to the heart was made through the fifth left intercostal space; it was seldom necessary to resect a rib. To reduce the risk of emboli the auricular appendage was opened without clamping but after the insertion of two thread purse-string sutures. Any thrombus in the appendage was usually palpable and could be dissected out with finger or scissors before any attempt was made to split the mitral opening. The split was made with the finger alone in 16 patients; in five Brock's knife, as modified by one of us (Lentin, 1955), was needed; and in four patients the valve was not altered. While the mitral opening was being manipulated the anaesthetist maintained carotid compression.In assessing the severity of the disease we adopted the criteria used by Baker et al. (1952) and later summarized (Baker et al., 1955) in the following grades: 1, slight disability; 2, moderate disability; 3, gross disability; and 4, total incapacity. Two of the three patients in grade 1 were brought to hospital on account of near-fatal attacks of pulmonary oedema. ResultsAll patients who had their chest opened for intended valvotomy have been included (see Table). There One of the deaths occurred in a patient who had an auricular appendage which was too small and the heart was not entered; she remained in congestive heart failure and died 23 months after her operation. Another death occurred 11 months after an incomplete and unsatisfactory mitral dilatation, which was, however, followed by temporary improvement; the patient developed auricular fibrillation a few weeks before she died. In the third fatality the patient was known to have a degree of aortic stenosis: a tight fibrous mitral orifice was found, which failed to yield to manipulation, and she died in pulm...
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