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TWO CASES OF " CORSET CANCER," WITHREMARKS ON THE ORIGIN AND

SPREAD OF CANCER.1BY R. CLEMENT LUCAS, M.B., B.S. LOND.,

F.R.C.S. ENG.,SENIOR SURGEON AND LECTURER ON SURGERY AT GUYS HOSPITAL;

CONSULTING SURGEON TO THE EVELINA HOSPITAL FOR CHILDREN.

MUCH attention is now being directed to the origin andspread of cancer and, whilst a committee of investigation isat work to endeavour to track the disease to its initial.causation, any new site of origin to which attention has notbeen directed may be of interest to the profession. I havetherefore taken this opportunity of drawing attention to amode of onset-I am almost inclined to say mode of entry-in the immediate neighbourhood of the breast which atfirst is not in the breast and only spreads to the breastsecondarily or by extension contact. Three cases of thismode of origin have recently been under my care but thereport of one of them has unfortunately been mislaid and Ican only give the details of two.The site where this carcinoma attacks the skin and

cellular tissue is over an upper and outer radiant from thenipple corresponding exactly to the point where the upperedge of a corset crosses the edge of the pectoralis majormuscle. It occurred on the right side in each case and inwomen whose occupations led them to an undue use of theright arm and in consequence to an excessive friction of theupper edge of the corset over the edge of the pectoralismajor muscle at the point indicated. The friction of thecorset at this spot is therefore the cause of the cancerousprocess developing in this situation and to express the fact Ihave given it the name of "corset cancer. "CASE 1.-The first case was that of a single woman, aged

47 years, who was admitted under my care in Guys Hospitalon Oct. 30th, 1901. Her parents were both living and healthyat an advanced age and previously to her admission hergeneral health had been always good. She was a workerin a fur factory and her employment for years had been toscrape the fur of rabbits skins with a blunt knife so as todraw out all the long hairs and to reduce them to a uniformlow level, after which they were dyed to imitate seal-skins and other valuable furs. For many hours everyday her arm was carried backwards and forwards inthis work and her pectoral muscle moving to and frowhilst she leaned over her bench pressed the softtissues injuriously against the upper edge of her corset.In March, 1900, the patient first noticed a hard swellingof about the size of a nut situated above, and to theouter side of, her right breast. It continued to grow, remain-ing hard and painless except when pinched or pressed upon.After a time she noticed that the pressure of the corset inher work caused her pain and she left off wearing it. Amonth before her admission the lump broke down and beganto ulcerate. When admitted she had the appearance of astout, plethoric, healthy, middle-aged woman. Above, andto the outer side of, the right breast close to the anterior foldof the axilla was a round raised ulcer about one and a halfinches in diameter with a definite raised margin and a dis-charging surface. Underneath the ulcer could be felt ahard lump of about twice the diameter of the ulcer butfreely moveable and in no way adherent to any deeperstructure. The patients appetite was good, the bowelswere regular, and the temperature was normal. On theback of the patients neck was a red serpiginous rashrunning in incomplete circles and curved lines and tendingto desquamate. When seen by me on Nov. lst it wasdiagnosed as a case of " corset cancer" but as theserpiginous eruption gave a suspicion of syphilis five grainsof iodide of potassium were given every six hours. Onthe 9th the report stated that she had been ailing withtoss of appetite and pains in her right arm, wrist, andhand, and also in the right thigh. On the 19th the painsin her joints had ceased and no effect had been producedon the ulcer by antisyphilitic remedies. It was there-

Ifore determined to remove the growth. A.C.E. mixture1 A paper read before the Brixton Medical Society on March 17th,

1904.

was administered and an elliptical incision in a transversedirection was made to include the growth. The incisionswere carried through the edge of the breast and cellulartissue down to the pectoral muscle, the fascia of which wasdissected up. From the centre of the upper incision another,three or four inches in length, was carried up into the axillaand the growth with glands and adipose tissue of the axillawere all dissected out together. During the operation somedischarge escaped from the deeper parts of the growth andcontaminated the wound. It was brought together withcatgut and a gauze drain was introduced below. On the 25thsome suppuration was noticed and the wound was thoroughlywashed out with 1 in 500 of formalin and packed withcyanide gauze soaked in formalin. On the 30th the woundwas cleaner and the temperature was normal. The patientwas discharged on Dec. 22nd. A microscopic examinationof the tumour showed the growth to be carcinomatous. OnOct. 27th, 1902, she was readmitted with a hard red growthover the upper aspect of the breast and two smaller ones,one being in the axilla. On the 30th an anaesthetic wasadministered and they were all separately excised. Shewas discharged on Nov. 24th. On Oct. 9th, 1903, shewas readmitted with several secondary growths about theskin over her right breast. There were no growths in theaxilla. The whole area affected, including the breast, wasexcised on Oct. 20th. A part of the wound was left togranulate. She made good progress and was sent to aconvalescent home on Nov. 4th, 1903.CASE 2. -The second case was that of an unmarried woman,

aged 59 years, who was admitted into Guys Hospital undermy care on Nov. 4th, 1903, for swelling and pain near theupper and outer edge of the right breast. She had beenemployed for 36 years in a laundry, carrying the iron back-wards and forwards over the linen for many hours every day.In appearance she was a tall, rather slight, delicate woman.She had had pleurisy twice and on one occasion an abscess inher neck. On the outer side of the superior external quadrantof the right breast was a small hard tumour causing a dis-tinct dimple in the skin. It corresponded exactly with thefriction level of the upper edge of her corset as it crossed themargin of the pectoralis major muscle. The tumour formeda depression of about the size of a shilling by its firmadhesion to the skin but was freely moveable on the tissuesbeneath. The breast and the nipple below were normal.One small gland was to be felt in the axilla. On Nov. 10than anaesthetic was administered and the tumour wasexcised. The incision was carried on into the axilla and thegland was excised. The tumour removed was proved to be acarcinoma by microscopic examination. She was convalescentat the end of a week and was discharged from the hospitalon the 18th but unfortunately the small wound left becamecontaminated at her home and she was readmitted with sup-puration and a high temperature on the 30th. The woundhad to be opened up as well as an abscess which had formedin her gluteal region, after which she recovered.

I have placed these two cases together for comparison andit will be noted that they were both single women advancedin life who had worked hard to gain a livelihood by theirown exertions. In each case the tumour commenced in pre-cisely the same position on the axillary margin above, and tothe outer side of, the right breast and each patient hadherself noticed the injurious effect of the margin of thecorset upon the spot where the tumour developed. Themovement of the right arm to and fro in their work wasagain very similar in the two cases, the first woman havingbeen employed for years in scraping the fur of rabbits skinsand the second for no less than 36 years in ironing in alaundry. To my mind, to use the phrase of a late distin-guished politician, there can be no shade of a shadow of adoubt" " that the injurious friction of the margin of thecorset for many years was the determining cause of thecancer developing at this particular site.

local irritation and lowered vitality determine the site.-This is but a new illustration of a well-established factthat different forms of carcinoma are apt to attackparts the vitality of which has been lowered or theresistance of which has been lessened by chronic irrita-tion, neglected ulceration, or cicatrisation. It was longago pointed out that epithelioma was apt to commenceon the edges of orifices where mucous membrane joinedthe skin and by a curious coincidence last October therewere in my ward for males at the same time a case ofrodent ulcer attacking the lower eyelid, a case of epitheliomaof the lower lip, a case of epithelioma of the prepuce and

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glans penis, and one of the margin of the anus, cases forming (an interesting group on which to found a clinical lecture. It is easy to surmise why the cancerous process favours these situations since the covering is there tender and at Ithe same time more exposed to injury and infection than iother parts of the body. The facts that cancer of the lower lip rarely occurs except in pipe smokers and that epithelioma