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THE MICROSCOPE AS A FACTOR IN THE DIAGNOSIS, PROGNOSIS, AND TREATMENT
OF MORBID NEW GROWTHS.
WILLIAM C. KRAUSS, M.D., F. R. M. S., BUFFALO, N. Y., President Buffalo Microscopical Club.
THE diagnosis of cancer after it has once made a permanent home in the human body, is no longer excusable. Time was, and not so far remote, when the clinician was obliged to wait for conclusive evidence before resorting to operative procedure, and in that time the growth had infiltrated neighboring tissues to such a degree that the life of the patient was imperiled. This condition of things. has changed materially within the past few years. The pathologist, armed with a modern microscope and himself trained in the modern methods of investigation, can give the surgeon almost positive knowledge concerning the malignancy or benignancy of the growth in question. The examination need not be delayed until the patient is under the anesthetic, but by means of a trocar (emporte-pièce histologique of Duchenne) small sections of the tumor may be removed and examined during the early growth, and its character determined. Should its location be upon dangerous ground, such as in organs or tissues where there is constant irritation, or where there is at times increased physiological action, or where there is conjunction of tissues derived from the epiblast and mesoblast, then repeated examinations are necessary to detect any degenerative change which may alter the character and consequent diagnosis of the neoplasm. In fact, so important is this that not only will a single examination be insufficient and inadequate, but several such microscopic examinations should be made by two or more equally skilled pathologists. Consensus of opinion should be arrived at as early as possible, and communicated to the surgeon in such terms that his duty will be forcibly impressed upon him. A single examination by a single observer means little or nothing, when from the clinical standpoint there is the least shadow of a doubt as to its nature.
The pathologist who is called upon to judge whether a small piece of tissue is normal or abnormal, and, if abnormal, whether it be benign or malignant, must have, in the first place, a thorough knowl
edge of the anatomical and histological elements of the various tissues of the body. Furthermore, he should be acquainted with the various steps in the development of such tissues, their transformations and processes of growth during the embryonic stage, and the functions which they are to assume at the close of fœtal life. The onward tread of science within the past few years has made it necessary for the pathologist to study. more the causation of disease and diseased processes, and to trace, if possible, the origin to a specific germ or bacterium. As yet, bacteriologists have not definitely taught us of this causative relation, although some observers have made cultures from and discovered bacteria in the tissues of tumors.
These allied sciences, stepping-stones to pathology, must be fully mastered if the investigator expects to attain anything like accurate results. Especially in histology is much experience and personal application essential. No one can hope to pass judgment upon a diseased tissue if the picture and nature of the healthy normal tissue be not continually before his eye and mind. The only way to secure this indispensable knowledge is by careful, painstaking work with the microscope in a well-equipped histological laboratory.
Having this fundamental knowledge and training, the investigator must follow some classification, and none is more perfect and universally accepted than Virchow's, based upon the germinal layers from which the original tissue giving rise to the neoplastic growth was derived.
It is often by exclusion that a diagnosis must be made, and to follow out this process one must be acquainted with the different forms and varieties, divisions, and subdivisions. With the satisfaction of being able to place every tumor under its proper head, it is not a very difficult task to compare the cells of the mesoblastic or connective tissue growths with their normal prototypes, and to classify them accordingly.
Characteristics of Tumors. We know by observation that tumors tend to reproduce their like, and that this tendency is inherited sometimes through several generations. As a rule, the same characteristic cell is reproduced, and thus the knowledge gained from the father may be applicable to the son.
Tumors follow, in the majority of cases, the type of tissue from which they spring, or, in other words, are homoplastic. A neoplasm growing from muscle, or nerve, or cartilage, is generally composed of that particular form of tissue as the case may be. Sometimes, however, the tumor tissue changes to that of a higher type, as a fibroma to a chondroma, but never a fibrous tissue to an epithelial. This last characteristic is, according to an important law, known as the specific nature of tissues, founded upon the fact that a tissue derived from one germinal layer cannot change to a tissue developed from a different germinal layer.
a tumor of the mesoblastic or connective tissue group is not liable to become a tumor of the epiblastic group.
The location of tumors is an important aid to the pathologist; for, as we have just seen, tumors tend to grow from tissues typical to their own. Malignant tumors, on the other hand, grow where tissues derived from the different germinal layers meet, as about the lips, larynx, rectum, etc., where there is constant irritation, and in those organs with increased physiological function, as in the mammary glands, uterus, etc.
Being cognizant of these facts, the pathologist is prepared to listen to the clinical history, and to make an examination of the growth in situ, or, if it has been enucleated, to examine it in the laboratory. The clinical history should never be underestimated or neglected; the daily condition of the patient as noted by the surgeon or family physician may give valuable information regarding the character and growth of the tumor, especially if it be a malignant one.
A tumor growing on dangerous ground in a subject past middle life, accompanied with constitutional disturbances, is, in the majority of cases, apt to be carcinomatous, and calls for speedy action. On the other hand, a circumscribed, nonadherent, globular mass appearing under the skin or scalp, may grow for years without the least danger or perhaps inconvenience.
The appearance of the neoplasm in situ gives many diagnostic points. To see the form, color, appearance of the central mass, edges, etc., in many cases alone solves the problem. The appearance of the myxoma, cholesteatoma, melanoma, and others is characteristic if
not pathognomonic; and although it is not judicial to make a snap diagnosis and forego further examination, nevertheless in many cases the character of the tumor can be thus predetermined.
To the touch, the mass appears hard or soft, adherent or non-adherent, even or uneven, lobulated, sessile, or pediculated, as the case may be.
The condition of the neighboring organs, tissues, and glands should not be forgotten. Infiltration of the adjacent tissue and chain of lymphatics is quite characteristic of the carcinomata. In cases of suspected malignant disease of the internal organs, the diagnosis is greatly strengthened by finding the lymphatic glands of the groin enlarged and hardened. The carcinomata and sarcomata are the only tumors which form metastases, the former through the lymphatic, the latter through the blood vessels.
The appearance of the tumor on section sometimes discloses important changes in its interior. As such may be mentioned a beginning of degeneration, formation of cartilaginous nodules, infiltration with calcium salts, hemorrhages into its meshes,
But the most important examination is still to be made, namely, the microscopical. The tumor may be examined in its fresh state, or may be hardened and carefully examined at a later period. Many times circumstances demand an immediate examination and diagnosis. This may be done by hardening the small mass in a freezing microtome, or, better still, to tease carefully a small section and compass them between two cover glasses, grinding them slowly to make as thin a layer as possible. The cover-glasses should then be separated by gliding one off from the other (not picking it off), and mounting temporarily in glycerine or brine. To stain these fresh specimens I use a 25 per cent solution of glycerine and ammonia (carmine solution), it serving at the same time as a mounting medium. The tumor cells take the stain kindly, and permit of a very satisfactory examination. To make permanent specimens, I harden the tumor in alcohol, and stain with hematoxylon or ammonia carmine.
The position that the microscope takes is then a most important one. Upon its decree depends the diagnosis, prognosis, and treatment of the tumor in question,
and the involvement of the life and happiness of the patient.
Several cases which have recently come under my observation, illustrate better than words the value of the microscope in this branch of our science.
Case I, referred to me by Dr. R.:Scrapings were brought me, taken from a growth seated in the larynx just above the vocal cords. Two previous examinations by skilled pathologists had been made, and both declared the neoplasm to be non-malignant. Continuing to increase in size, and complicating the normal functions of the trachea and esophagus, the tumor was removed and sent me for examination, which was immediately made. My diagnosis was carcinoma of the larynx, and with it the prognosis and treatment. The infiltration of the neighboring tissues had advanced to such a stage that laryngotomy or even total extirpation of the larynx was contraindicated. The treatment was directed toward relieving the pain and suffering. A few weeks later the patient died. Had, perhaps, several examinations by the three pathologists been made early in the disease, and unity arrived at, a timely operation might have prolonged the life for several years.
Case II, referred to me by Dr. M.: Mary F., 20 years of age, born in Ireland, entered the Sisters' Hospital, Buffalo, N. Y., on Nov. 14, 1890, with the following history: She is a domestic and has been obliged to do a great deal of sweeping, during which the handle of the broom rubbed against the breast-bone. She ascribes her complaint a tumor on the breast-bone-to this cause. The swelling first appeared eleven months ago, and has been growing larger steadily, till now it is the size of half an orange and extends from above the third to below the fifth rib. Four months ago the glands in the right axilla commenced to swell, and there is now found here a conglomeration of glands as large as two fists, completely filling the whole axilla, but yet somewhat movable. Two months ago the glands in the left axilla commenced to swell and are now as large as a hen's egg. During the last few weeks the glands in both supraclavicular regions have commenced to enlarge. The tumor over the sternum is immovable, presents a feeling of false fluctuation; the skin is normal in color and not adherent. She
has sharp, shooting pains radiating from the tumor in different directions; has lately commenced to lose flesh, but is yet in pretty good health. There are no symptoms of any growth in the anterior mediastinum, such as hoarseness, displacement of heart, difficulty of breathing, or interference with circulation.
An examination revealed, to the surprise of all, the most malignant of malignant tumors a melano-sarcoma. Carefully removing every vestige of the growth and the infiltrated glands, and by strict antiseptic precautions, the wound healed nicely. To the present day, the patient has suffered no relapse, which to her will mean certain death. Had the microscopic examination been neglected or discarded in this case, a different condition of things would have been the result.
Case III, referred to me by Dr. F.: Scrapings were sent me coming from the cervix uteri of a middle-aged woman. The diagnosis arrived at by the physician, and one perfectly justified by the age, history, and symptoms of the patient, was carcinoma uteri. A complete hysterectomy was the operation in view. The microscope, however, radically altered the plans of the gynecologists, and a curette was substituted for the scalpel in the removal of a uterine polypus.
Generally the characteristic tumor tissue is easily recognized and correctly diagnosed. Some trouble is encountered in diagnosing some forms of the carcinoses, especially if degeneration or breaking down of the alveolar structure has taken place; but in such instances the complete examination must afford some light as to their character, and a probable diagnosis can be determined upon. Should such a tumor occur on dangerous ground, several examinations by one or more skilled pathologists should be made, and, if possible, the different views unified.
Bearing these few suggestions in mind, then, it is not the most difficult task to make a correct diagnosis of a morbid new growth.
To illustrate the value of preliminary examination, I will cite a few cases of brain tumor which have lately come to my notice :
Case I.-A brain presenting a large ovoid mass in the left frontal lobe was brought me for examination. The tumor was gelatinous in appearance, soft, compressible, almost fluctuant. These few
qualities left no doubt in my mind as to its being a myxoma, and the microscopical examination verified my diagnosis. These tumors are of rather frequent occurrence in the brain, since the neuroglia is allied to mucous tissue, and is consequently prone to engender tumors of this variety.
Case II. An autopsy was made on a man who intravitam was declared to have a tumor either in the interior or base of the brain. On removing the cerebrum from the skull, a large pearly white mass was found at the base of the brain cephalad of the pons. It was composed of white, rounded pearls, with a nacreous luster, packed together in dense concentric masses. The peculiar appearance due to the closely-packed, thin cells is characteristic of the cholesteatoma, a tumor of endothelial or epithelial origin1 growing from the membranes at the base of the brain.
Case III-A brain was sent me from a neighboring city for examination. found the hypophysis or pituitary body normally the size of a bean or pea about as large as a marble, and producing pressure upon the chiasma cephalad and caudad, it was partially planted in the space between the crura. On cutting the periphery, a gritty, rasping sound was heard, and on cutting deeper, the scalpel came in contact with a hard, stony substance. The cut surfaces were chalky white, with many glistening points, and crumbled into minute particles. My diagnosis was calcareous degeneration of the pituitary gland. On examining under the microscope, minute crystals could be seen throughout the field, while the larger portions appeared dark by transmitted light, white and glistening by reflected light. On adding a drop of strong nitric acid under the cover-glass, these calcareous masses (carbonates and phosphates of calcium) dissolved, and the evolution of carbonic acid gas could be distinctly seen under the microscope.
1. That a tumor should be examined as early as possible by one well versed in pathological microscopy.
2. That repeated examinations should be made from time to time, particularly if the clinical history is one arousing any suspicion as to its character.
3. That when a tumor occurs on dangerous ground, the services of two or more skilled pathologists should be called into requisition, and its nature carefully determined.
DEDUCTIONS FROM TAPELINE MEASUREMENTS.
BY PROF. HENRY CLARK.
WHEN a series of examinations of men by tapeline has been made, it is yet a rather difficult matter rightly to read their significance. We know that not every increase in girth is a decided benefit to the man; nor, necessarily, does even a considerable decrease in general girth measures betoken any detriment to his condition or to his improvement in right lines, but that the particular nature of such changes as may have been noted is what is of most value. Changes of what kind? These can be explained, I believe, by a very simple principle, one which is long, perhaps, in attaining and realizing, which yet takes but a word in stating: that symmetry, or a proper proportion of parts to each other, is the best, or in some cases the sole and unanswerable, test of whatever good condition the man has attained. Whenever the condition of the subject is such, then, that he tends toward greater symmetry, is it reasonable to 'guess, in the absence of other data, that he is nearing a better condition, so that what treatment he has been following out to restore him from a bad or low condition is likely to be so far grateful and significant of improvement? But when a decided aberration from normal proportion not only persists but increases, we may look in this case for some diminution of his vitality or his strength, if he is a well man, and for positive ill health if he is ailing. These, if they be only indications, ofttimes prove valuable as such, and may show when a physician may look for and correct pathological tendencies.
In one's own experience, it is also of benefit to have the judicious eye of a
practical trainer upon him from time to time, who, tapeline in hand, may verify any faulty judgment the eye, unaided, may make.
For nothing is so delusive, as we all know, as a hasty glance where exactness is desired. There is at this time, in a gymnasium where the writer daily exercises, a well-developed, heavy, but quite active college athlete. To the eye, this man is a puzzle. All usual tests are at fault when one would account for his excellence in boating, football, and such games in general as require readiness as well as force. For to the eye, in his usual gymnasium dress, he appears faulty, in a small waist and narrow pelvis,
a condition fatal to strength, push, or staying-power, and not entirely consistent with robust health. Yet he is a good man, in spite of all apparent defects, and they the most radical. It was only when this man was seen without his parti-colored costume that the puzzle came to a clear solution. The dark-blue "trunks," the white shirt, distorted to the eye (by a wellknown delusiveness of vision), a make-up which is really symmetrical, so that without in this case any actual application of the tapeline, one could readily correct, when the man stood before him, unclothed, that erring judgment made by what appeared to the unaided eye a false proportion of elements of excellence. But it must be said, after all, that a tapeline examination would alone decide what kind of man he is, and show that after we can learn by inspection all which can be seen, the test of actual measurement is ultimate knowledge.
Two other instances arise. A first-rate man, who has a record for local results in several sparring bouts, has for two or three years at a time been in course of occasional exercise in gymnasia, where, to the eye, in his ordinary gymnasium costume, he appeared to the writer to be over-developed in chest, and consequently too small across the pelvis for symmetry. I happened not long ago to step into the locker-room where he was about to be handled by his trainer, for a coming glove-contest. (He whipped his man a few days afterward, showing good, sound condition.) I saw while the trainer was rubbing down his man, that the man was remarkably well-developed in the region. where he seemed to have been defective, and, whimsically enough, to be so broad across the pelvic line that he himself
asked me if I thought his proportions were altogether masculine.
A second case exactly like the first is seen in the excellent breadth of my own instructor's proportions, who seemed on the stage awhile ago, at an exhibition (before he was seen at the better advantage of a late observation), to be quite out of proportion in a thin pelvis and narrow hips. He is, as I know very well, an excellent man, and barring a rather too rough skin and slightly too small pulsation, is as good a man as the average of athletes. These comments may be thought of in the way of caution in judging, and of recommendation to wait for a disclosure of the subject before a conclusion is reached. And at the risk of telling what some of my readers know quite as well as I, it must be said that I do not find the artistically beautiful man always to be a good man. In his street costume the athlete appears always to me to be "round-shouldered." So he is. The extra training (perhaps early in life) of his shoulder-muscles has unduly, though not by any means excessively, enlarged the shoulder and back, so that he is actually thicker through than other men in this line, as may be shown if a girth be taken round the shoulder. Yet this may not be a defect.
Talking a few days ago with two "tumblers" who are now training for the stage, one told me that his neck girth was normal when he began training for the three-brother-act" he is soon to be engaged in, but was soon so much increased as to be quite noticeably larger than usual. A beautiful fellow, who has been recently getting ready for a trapeze act, standing on his head being a part of the act, has a variation of two inches in favor of neck-girth over calf-girth, which he thinks is the result of his exercise. The diagonal neck muscles are not larger than usual, but the side muscles alone. He has likewise a thickening up of such muscles as aid him in steadying himself while head downward, the thick inside shoulder-muscles being noted, as used. This man is about twenty-three years of age, and consequently subject yet to some. variations, by means of special movements, as he trains for his work. None of these little extra differentiations, however, spoil the general symmetry of these persons, who are altogether very good men, and in excellent condition. It is in