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Biopsy
BIOPSY JOSEPH C. BLOODGOOD,
M.D., P.A.C.S.
BALTIMORE, MD.
I
T was very diffIcuIt to get facts in regard to the dangers, if any, of biopsy, because unti1 recentIy there has not been a su&ient number of cases properIy observed and recorded, and, in the first fifteen or twenty years of operative surgery since 1890, the vast majority of cases of maIignant disease did not require a biopsy to make the diagnosis. Before there was any widespread dissemination of correct information in regard to cancer and when patients came under the observation of surgeons because of the possibiIity of a maIignant tumor in some part of the body, the incidence of cancer varied from 80 to more than go per cent and the necessity for biopsy was probabIy present in Iess than I per cent. Today, in some cIinics, the number of patients seeking advice at once or within a month or Iess of the first symptom, and the incidence of cancer faIIing to 20 per cent and Iess means that the necessity for biopsy is rapidIy rising to more than 50 per cent, whether the treatment be surgery or irradiation. ApparentIy the chief danger from biopsy today is a misinterpretation of the microscopic picture, and the chief danger in this is that a benign Iesion wiI1 be diagnosed maIignant and the patient wiI1 be subjected to an immediate unnecessary operation or irradiation. NevertheIess, there is a great opportunity for cooperative coordinated and sympathetic investigations among a11 those in the medica and denta professions who are interested in the probIem and responsibIe for the resuIts. I have graduaIIy come to the concIusion that it wouId be very much wiser for any member of the medica and denta professions who feeIs that biopsy shouId be resorted to before any decision as to treatment, not to perform the biopsy unless he is prepared, with his associates, to decide without asking for 331
332
JOSEPH
C. BLOODGOOD
outside heIp, what to do after the sections have been examined. That is, he must be wiIIing to assume the entire responsibiIity of even the immediate frozen section diagnosis. When this member of the medica or denta profession and his immediate associates are unwiIIing to assume a11the responsibiIities of a biopsy, they shouId obtain the advice of the individua1 or group or cIinic to whom they wouId have referred the sections, had a biopsy been performed and they found themseIves unabIe and unwiIIing to decide what to do. I have ampIe evidence to prove the correctness of this statement. The number of individuaIs or diagnostic groups or cIinics who are abIe today to decide, from a microscopic section, what the disease is and what proper treatment shouId be foIIowed, is fortunateIy on the increase, so that any member of the medica or denta profession couId get their advice by teIephone, teIegraph or Ietter aImost immediateIy, and there wouId be no danger from deIay in first finding out the best way to perform the biopsy and whether it shouId be done or not before irradiation, and how it shouId be done. And, in addition, there wouId be IittIe or no danger from deIay of sending the sections to this diagnostician or diagnostic cIinic. The chief mistake made today is performing the biopsy before consuIting the diagnostician or the diagnostic cIinic. The education of the pubIic has proceeded so rapidIy that the reIative number of patients with IocaI Iesions on whom a biopsy must be done has not onIy rapidIy increased, but the difKcuIties of making a correct microscopic diagnosis have muItipIied stiI1 more rapidIy. AI1 surgica1 pathoIogists agree that it is impossibIe today to furnish a suffIcientIy trained and experienced pathoIogist to meet these demands, except in the Iarge cities. Many of the smaIIer hospitaIs in Iarge cities and many of the hospitaIs in smaIIer cities need diagnostic heIp, and there must be biopsies in which there is an interva1 of time between the biopsy and the operation if indicated. There is no diffIcuIty, however, for those who require the heIp of such speciaIIy trained and equipped diagnosticians and
BIOPSY
333
diagnostic chnics, to get this assistance before the biopsy, and to Iearn whether irradiation shouId be tried first, and to obtain the very Iatest views on how the biopsy shouId be performed. As a matter of fact, this method, undoubtedIy the best for the patient and for every one responsibIe for the patient, is resorted to more and more in a most eficient and satisfactory way. However, there are stiI1 too many biopsies performed without these precautionary measures. This correct information has not reached the majority of the medica and denta professions. The education of the peopIe is proceeding so rapidIy, and their response to this correct information is so prompt that the most experienced diagnosticians in the Iargest cIinics are having great diffrcuIties in distinguishing the benign from the malignant in breast tumors, Iesions of bone, pieces of tissue from the cervix, curettings from the uterus, prostatic disease, bIadder tumors, suspicious gaI1 bIadders, indurated areas in the pancreas, pieces of tissue removed by the Iaryngoscope, the bronchoscope, the esophagoscope, the cystoscope; Iymph gIands removed for diagnosis, and practicaIIy wherever a piece of the IocaI Iesion is excised for diagnosis. These borderIine tumors I have been personaIIy observing and recording since Dr. HaIsted and Dr. WeIch turned over to me in 1892 the surgica1 pathoIogy of Dr. HaIsted’s cIinic at Johns Hopkins HospitaI. I have reported on these borderIine tumors in many pubIications, especiaIIy since I g I 3. Previous to 1915 I was rather incIined to the view that naked-eye diagnosis was sufhcient. Now I know that it is not. Recent experience teaches me that it is much safer for the patient to have the diagnosis by two or more pathoIogists than by one, even if the Iatter is the best avaiIabIe. This increasing necessity for the diagnosis by two or more pathoIogists makes it more and more diffrcuIt in operative cIinics which have avaiIabIe onIy one pathoIogist, to meet the demands of this microscopic diagnosis as the number of earIy cases increases. The tremendous change in the necessity for biopsy performed properIy and at the proper
334
JOSEPH
C. BLOODGOOD
time, and the necessity for two or more pathoIogists with special training make it more and more diffIcuIt for any singIe cIinic to meet the demands of today. There is more and more evidence to urge the necessity of ascertaining at once, if possibIe, what the dangers are from a deIay of a few days between a properIy performed biopsy protected if necessary by irradiation preceding and foIIowing it, and some operative. procedure. This wiI1 aIIow microscopic sections to be submitted to a number of diagnosticians or diagnostic cIinics. This is now being done more and more frequentIy throughout this country. So far as my investigations have gone, if the procedures are properIy carried out, there is IittIe if any danger. To repeat, the greatest danger today is that a diagnosis of mahgnancy, erroneousIy made on borderIine tumors, wiII Iead to an unnecessary radicaI operation. There is no harm in giving these doubtfu1 cases irradiation first, and there is no harm in continuing irradiation after an expIoratory biopsy in doubtfu1 and borderIine cases. If operation must uItimateIy foIIow, because the diagnosticians agree on maIignancy, the chances of a permanent cure are apparentIy IittIe, if at aII, affected by this deIay. The bookkeeping of a11 expIoratory incisions and biopsies with the records of the actua1 pathoIogy is, of itseIf, a diffIcuIt procedure, and when the records are properIy made and kept, the foIIow-up offers additiona diffIcuIties, and the most d&c& of a11 is to go over the records from year to year and try to discover if there is any danger in expIoratory incision into a maIignant tumor foIIowed at once by the compIete operation, or any greater danger if there is an interva1 of time between the exploratory incision for biopsy and the necessary operation. There is one thing for a11 of us interested in this probIem to remember. In the beginning there were more frequent expIorations into mahgnancy of a type in which the percentage of cures was very smaI1, or, if there was a biopsy, it consisted in the remova of the mahgnant tumor on the diagnosis of benig-
BIOPSY
335
nancy, and as a ruIe this mahgnant tumor was incompIeteI\removed. In addition, the interva1 of time between the first and second operative procedure was unnecessariIy Iong. Much of the fear of the dangers of biopsy in past years was due more to the maIignancy of the disease than to the danger of the biopsy, and many of the apparent bad resuIts of the biopsy were due not to the biopsy itself, but to the improper resort to this procedure or the improper method pursued. The point that we must remember is that we are to encounter in every IocaIity more and more frequentIy IocaI Iesions in which there must be a microscopic diagnosis before there can be any radica1 operative method or extensive and proIonged irradiation, and, due to the diffIcuIties of distinguishing borderIine Iesions, biopsy with an interva1 of time between the first and second procedure must necessariIy increase in frequency. AI1 of us must make more carefu1 records, be more particuIar in our foIIow-ups, and must constantIy restudy our materia1, so that we may find out exactIy the procedures that are Ieast dangerous in the dissemination of maIignant disease when it must be cut into to remove a piece for microscopic diagnosis. LESIONS
OF
BONE
I seIect this first, because in the majority of maIignant tumors of bone today a biopsy must be performed before the decision as to amputation or resection. As a matter of fact, the majority of sarcomas of bone remaining we11 five years or more after amputation, were subjected to biopsy without irradiation, and there was an interva1 of time of often two weeks between the biopsy and the amputation. In the earIy years the incision into the sarcoma of bone was made without a cautery and the wound was cIosed without the use of chemica1 or therma cauterization. Of the two five-year cures which I reported in 1920, in one there was a biopsy with an interva1 of two weeks before the amputation; the tumor was an osteogenic sarcoma. Drs. Geschickter and CopeIand have made a very carefu1 investigation of the five-year cures which
336
JOSEPH
C. BLOODGOOD
have now accumuIated in the SurgicaI PathoIogicaI Laboratory, and they find that in more than one-haIf of the 70 or more cured cases there had been a biopsy. This evidence is against the danger of a biopsy in Iesions of bone with reference to increasing the IiabiIity to metastasis, but not to the increased danger of IocaI recurrence in the soft-part scar shouId there be resection or curetting. We have sufficient recent evidence that if there is protection by preoperative and postoperative irradiation, there is no danger, except in a pure myxoma, from this expIoration for biopsy, even when the operation consists of resection or curetting onIy. ApparentIy the onIy bone tumor dangerous to expIore is the myxoma, and the greatest danger is when the myxoma has Iiquefied and the Iiquid gets into the soft-part wound. I have reported on this on a number of occasions. There is one exampIe of myxoma without Iiquefaction occupying the Iower end of the femur and its condyIe which was expIored more than seven years ago, the diagnosis of myxosarcoma made from the frozen section, and the immediate curetting of the bony she11 with soIdering irons. This was done at my suggestion by the Iate Dr. Roxey of PortIand, Oregon. This patient is Iiving, without evidence of recurrence and a weII-functioning Iimb at this date. But, to repeat, there was no Iiquefaction of the myxoma. FortunateIy, the majority of authorities on bone tumors agree to the importance of the immediate irradiation of every bone Iesion unIess its x-ray pictures show a definiteIy benign Iesion. I aIso think it wouId be safer, when expIoratory incision has been decided upon in a bone Iesion, to be prepared with eIectric cautery, which I think is better than the eIectric needIe, and, if the Iesion is centra1, to be prepared with soIdering irons and a 50 per cent soIution of zinc chIoride. These are the onIy means of attack on a myxoma that has Iiquefied. The greatest danger of chondroma or chondrosarcoma is to Ieave a piece in the soft-part wound. Today I was Iooking over the x-rays, gross specimens and sections of a patient now Iiving,
BIOPSY
337
more than five years since the amputation of her femur for a chondroma, possibIy a chondrosarcoma of the Iower end of the femur. In this case, there had been three expIoratory incisions with partia1 remova of the tumor. LESIONS
OF
THE
BREAST
Now that the majority of women seek advice within a month after the first symptom caIIing their attention to one or both breasts, the incidence of cancer wiII be Iess than IO per cent in a11 cases, and Iess than 50 per cent in a11 cases subjected to operation. When the breast Iesion is cIinicaIIy maIignant, many surgeons resort to irradiation first. This subject wiII be deaIt with in a Iater paper. When the Iesion of the breast is smaIIer than a twenty-five cent piece and, whether it transiIIuminate cIearIy or darkIy, it shouId be excised, unIess, when cutting down upon it, a typica blue dome is brought readiIy into view. When this happens, the bIue dome shouId be nicked to observe the character of the fluid and the waII of the cyst. When the cyst waII is smooth and the contents cIear or cIoudy it is unnecessary to remove the cyst. SimpIy take a smaI1 piece of the waII of the cyst for frozen section. If there is no bIue dome, then the paIpabIe noduIe shouId be excised with a zone of normaI breast tissue up to the size of a twenty-five cent piece or a IittIe Iarger. When this has been removed, the surgeon pIaces it in the hoIIow of the Ieft hand on a piece of gauze or a toweI, and then bisects it, being carefu1 not to touch it with his own gIoved finger. If the naked-eye appearance and the frozen section are typica of a maIignant Iesion, pIace in the wound an aIcoho1 sponge, or one saturated in 50 per cent zinc chIoride and cIose the skin wound; then proceed at once with the compIete operation for cancer. The majority of authorities agree to this original conception of HaIsted. My recent experience taught me that if the pathoIogist can recognize acute carcinoma, the type that uItimateIy Ieads to cancer en cuirasse, nothing more shouId be done, except excision of the tumor and a zone of uninvoIved breast. The wound shouId be cIosed
JOSEPH
338
C. BLOODGOOD
and the patient subjected to a course of irradiation as quickIy as possibIe. The chances of this patient for comfort during the time she has to Iive are better without the compIete operation. This aIso wiI1 be the subject of another paper. The most diffIcuIt probIem in Iesions of the breast today is what to do when the expIoratory incision removed a microscopicaIIy doubtfu1 tumor. In my experience since 1893 the majority of the microscopicaIIy doubtfu1 tumors of the breast turn out to be benign, no matter what the operative procedure may have been. For this reason, I beIieve it wiI1 be safer to remove the tumor onIy and subject the patient to irradiation whiIe submitting sections of the tumor to a number of trained pathoIogists. UnIess they agree to the diagnosis of maIignancy, the chances are that the tumor is benign and enough has been done. LESIONS
OF
THE
SKIN
There seems no harm in subjecting any Iesion of the skin to a biopsy. But, when the IocaI Iesion can be compIeteIy excised under IocaI anesthesia without mutiIation, nothing is to be gained by cutting out a piece. The ruIe shouId be to remove the entire derma1 Iesion so that the IocaI operation wiI1 be sufficient no matter what the microscope wiI1 show. LESIONS
OF
THE
MUCOUS
MEMBRANE
OF
THE
ORAL
CAVITY
The same ruIe just given for the skin appIies here. But, in the mouth the Iesion may be smaI1, but so situated that its compIete remova is much more diffIcuIt than trying irradiation first. LESIONS
This has been going obtained that it has any an appreciabIe space of piece for diagnosis and
OF
THE
CERVIX
on for years, and no evidence has been eIements of danger, even when there is time between the excision of the smaI1 the irradiation or operation.
BIOPSY LESIONS
OF
THE
BODY
339 OF
THE
UTERUS
There is aIso ampIe evidence in favor of the safety of a curetting biopsy in Iesions invoIving the Iumen of the uterus. There is aIways suffkient time to submit the section to a number of diagnosticians. CONCLUSIONS
The chief danger of a biopsy, whether for a frozen section in the operating room or a fina fuIIy prepared section, is caIIing a benign Iesion maIignant. No one shouId have any diffrcuIty in obtaining advice as to the best thing to do before the biopsy and as to the method of performing the biopsy; aIso as to whether irradiation shouId precede biopsy. The next most important thing is for surgica1 pathoIogists to reaIize and practice that it is safer for the patient when the section, if possibIe, is carefuIIy studied by two or more pathoIogists. When good pathoIogists disagree, the Iesion is usuaIIy benign. When the pubIic is properIy educated to continuous medica care, biopsy wiI1 become a very frequent routine procedure, and there wiI1 usuaIIy be an interva1 of time between the biopsy and the fina treatment. We are a11 beginning to Iearn that a IocaI Iesion or a IocaI symptom needs first a most carefu1 cIinica1 study and a discussion as to whether, when and how a biopsy shouId be performed, and the most important thing of a11is the training of the surgica1 pathoIogist who studies the sections. These great changes are due to the reaction of the inteIIigent pubIic to the educationa campaign of the medica and denta professions which, in this country, has been IargeIy heIped by the American Society for the ControI of Cancer. The two best recent reviews on Biopsy, which practicaIIy cover a11the important Iiterature, are that by HeIIwig (Arch. Pathol., 14: 517-554, Oct. 1932) and that by McGraw and Hartman of the Henry Ford HospitaI (J. A. M. A., IOI : I 205, Oct. 14, 1933). These are important contributions to Biopsy.
340
JOSEPH
C. BLOODCOOD
I also refer my readers to three articIes by me on preoperative irradiation : I. When shouId irradiation with radium or x-ray precede operation or be empIoyed without operation? Ann. Surg., 96: 882-890 (Nov.) 1932. 2. Preoperative irradiation in cases of cancer of the breast with or without biopsy. Ann. Surg., 98: 933-940 (Nov.) 1933. 3. Radiology (May), 1934. I also caI1 attention to the foIIowing articles on Chronic Cystic Mastitis and borderIine breast tumors: In the Arcbiues of Surgery (3: 445-542, Nov., 1921) is my basic contribution on the PathoIogy of Chronic Cystic Mastitis of the FemaIe Breast. There are or ihustrations. In this articIe I give the evidence against any definite reIationship between Chronic Cystic Mastitis in a11 its types (both cystic and non-cystic) to cancer, changing the views that I expressed in Surgery, Gynecology and Obstetrics (3: 721-730, Dec., rgo6), in an articIe entitIed SeniIe Parenchymatous Hypertrophy of the FemaIe Breast, Its ReIation to Cyst Formation and Carcinoma. The Iast articIe on borderIine breast tumors wiI1 be found in the American Journal of Cancer (16: 103-176, Jan., 1932). This has 57 illustrations. Those who propose to attend the meeting of the surgica1 section of the American MedicaI Association in CIeveIand this June shouId read these contributions with the present articIe and prepare themseIves for a further statement on biopsy in breast tumors and the importance of irradiat.ion after the excision of a borderIine breast tumor whiIe waiting for the diagnosis of the consuIting group of pathoIogists. DISCUSSION DR. BRADLEY L. COLEY, New York, N. Y.: In osteogenic sarcoma, whiIe there is a smaI1 percentage of cases in which radiation, in our hands, has accompIished a striking resuIt, the vast majority are very radioresistant. Therefore, it is of great advantage to know with what type of tumor we are deaIing in a given case. We surgeons recognize the dangers of indiscriminate biopsy which pathoIogists have caIIed to our attention, and I beIieve that nowhere is such a procedure more dangerous than in bone tumors. When the biopsy wound is not cIosed in layers without drainage and primary union is not obtained, the resuIts are bad; fungating and infected tumors interfering seriousIy with the future treatment of the cases. We have a method of obtaining biopsy material which was deveIoped IateIy by Dr. Hayes E. Martin of the Head and Neck Department, Memoria1 HospitaI, and which has been extended to other departments of the hospital. We use it frequentIy in bone tumors. Two years ago we* * C&y, Higinbotham and Elks: n.s. 13: No. z, August, x931.
Aspiration
biopsy in bone tumors.
Am. J. Surg.,
BIOPSY reported then
341
on 35 cases in which aspiration
we have
had 75 additiona
cases.
biopsy
was performed,
EIiminating
which were IargeIy head and jaw cases, we now have biopsy
and since
IO
of the first group,
100
cases of aspiration
of bone tumors.
TabIe
I shows the various
was performed
with the positive
types
of tumors
and negative TABLE
I
in which aspiration resu1t.s obtained
biopsy
in each type:
Total
Positive
Negative
Osteogenic sarcoma. Endothelial myeloma. Giant cell tumors. MuItipIe myeIoma. Metastatic. . . InfI ammatory-chronic,
.:
39
28
II
7
7
0
17 8
13 7
4 I
I9
I2 3
7 0
I
0
3 I
Pyogenic .
T.b................. Syphiiis. . Echinococcus. Benign tumor..
2
I
I
0
I
I
0
I
0
I
3 I
100
75
25
Total
Positive
Negative
-
TABLE
II -
-
Skull
Vertebra. Rib. . Sternum. CIavicIe
Scapula. Humerus. Radius. . UIna...... IIium...... Ischium. Sacrum. Femur. Tibia. FibuIa. MetatarsaI, Phalanx
2 I
0
1
7
7
0
0
4
3
1
4
3
I
4
3
I
I3 2
9 2
4 0
2
0
16
10
:
1
1
0
4
3 22
5
27 6
3
I 3 0
4 2
4 2
I
I
0
75
25
100 -
2
0
342
JOSEPH
C. BLOODGOOD
Table II shows the various bones upon which aspiration biopsy was performed. It in&ides broadIy every bone in the body. The frequency corresponds fairIy cIoseIy to the incidence of primary bone tumors in . _ various bones. TABLE III SUMMARY
-
/I
Confirmation
bJo confirmation
&he-
quent course
Set Amputionc:d Biopsy tation Autops? f CZOI
rotaz
Positive aspirations: I. Tumor (a) Complete. (6) Satisfactory. z. Not tumor.. Negative aspirations: I. False positive. 2. False negative.
_ -
6 6 4
6 8 0
3 I I
35 31 9
I 9 ___~ 26
I 2
I 2
3 22
17
8
100
-
Referring to TabIe III, one sees that in 35 cases the diagnosis rendered on aspirated materia1 was compIeteIy satisfactory; by this term we mean that the pathoIogist was abIe to report the specific type of tumor present, e.g., “giant ceI1 tumor” or “metastatic carcinoma,” etc. In 31 other cases, which we have considered as satisfactory, the pathoIogist reported the presence or absence of a tumor and whether or not it was malignant, but was unabIe to cIassify it further, e.g., “ceIIuIar malignant tumor,” “radiosensitive” or some “type of sarcoma possibIy neurogenic.” Here at Ieast was vaIuabIe information which, in conjunction with clinical and radiographic evidence, wouId in most instances permit an accurate diagnosis. Here Iet it be said that even with ampIe gross amounts of tissue removed by operative means we may in unusua1 cases be unabIe to determine the exact type of tumor with greater accuracy than can be done from aspirated materia1. In 9 cases we Iearned from the aspiration that the process was not a tumor. Thus in 75 of the IOO cases we obtained essentiahy vaIuabIe information. The remaining 25 cases, cIassed as negative aspirations, may be divided into two groups: (I) FaIse positive (3 cases) ; and (2) faIse negative (22 cases). The faIse negative cases comprise those in which, though other strong evidence of a tumor existed, stiI1 the materia1 aspirated contained
BIOPSY no tissue upon which a histoIogica1 diagnosis couId be made. These failures mean nothing except a faiIure to obtain aspirated material from the invoIved area or insuffrcient in amount to permit of a pathologica opinion. The smears in these cases were reported as showing onIy bIood, fibrin, muscle, fat, etc., no tumor ceIIs being identified. Those 22 faIse negative cases are not a reflection on the method but a reflection on our abiIity to introduce the needle into the proper pIace in the bone to obtain definite information. I fee1 that as we become more accustomed to the use of the method we wiI1 obtain an even higher percentage of successfu1 aspiration biopsies. The 3 faIse positive cases shouId, perhaps, not be cIassed as negatives, for in each instance a report of a maIignant tumor was made, but subsequent histoIogica1 evidence proved that the type of tumor differed from that reported on the basis of the aspiration. I fee1 that this method has, in our hands, received a suffrcientIy prolonged period of trial to warrant recommending it to others, but with this reservation: It puts an unusua1 demand upon the pathoIogist who is caIIed upon to make a diagnosis from such minute bits of tissue. AIso, there are some types of bone tumor, notabIy, meduhary tumors with an intact cortex, in which it is not appIicabIe. ShouId the aspiration biopsy be unsuccessfu1, one is then abIe to perform a forma1 surgica1 biopsy shouId the indications for it be present. DR. J. SHELTON HORSLEY, Richmond, Va.: When Dr. BIoodgood correIated the x-ray picture and the histologic and clinica findings on the giant ceI1 tumor of bone he took it out of the sarcomas, with which it had been confused, and prevented many unnecessary mutiIating operations. I doubt very much that biopsy of a bone tumor by the exceIIent method Dr. CoIey has so we11 described can be of genera1 use. It requires a great dea1 of ski11 to make a biopsy by this method and, as Dr. CoIey showed in the negative reports, sometimes it is impossibIe to get satisfactory tissue. It aIso pIaces an extra strain upon the pathoIogists and, as Dr. BIoodgood has stated, they are aIready strained too much. The method would be appIicabIe onIy to a very few highIy organized hospitaIs and not in a genera1 way. I rather think that stress upon the proper interpretation of the roentgenogram, and the cIinica1 symptoms, wiI1 usuaIIy be sufficient in the diagnosis of bone tumors. With regard to breast tumors: It is a controversia1 question whether chronic cystic mastitis or Schimmelbusch’s disease causes cancer, but the important thing that is universaIIy agreed upon is to get practitioners to realize that tumors of the mammary gIand must not be massaged but must be sent to the surgeon as soon as possibIe. That is an oId, oId story, but within the Iast week I operated upon a woman who had been treated
344
JOSEPH
C. BLOODGOOD
by a practitioner who gave her some oil to rub on her breast for several weeks before I saw her. I found the axiIIary tissues Ioaded with cancerous Iymph nodes. These sIogans, such as never to massage a tumor of the mammary gIand unIess the. diagnosis of a benign condition is certain (and usuaIIy not then) are so trite that we overlook them ourselves but if we can spread that gospel it wiI1 do much toward cutting down the death rate from cancer of the breast.
M.D., P.A.C.S.
BALTIMORE, MD.
I
T was very diffIcuIt to get facts in regard to the dangers, if any, of biopsy, because unti1 recentIy there has not been a su&ient number of cases properIy observed and recorded, and, in the first fifteen or twenty years of operative surgery since 1890, the vast majority of cases of maIignant disease did not require a biopsy to make the diagnosis. Before there was any widespread dissemination of correct information in regard to cancer and when patients came under the observation of surgeons because of the possibiIity of a maIignant tumor in some part of the body, the incidence of cancer varied from 80 to more than go per cent and the necessity for biopsy was probabIy present in Iess than I per cent. Today, in some cIinics, the number of patients seeking advice at once or within a month or Iess of the first symptom, and the incidence of cancer faIIing to 20 per cent and Iess means that the necessity for biopsy is rapidIy rising to more than 50 per cent, whether the treatment be surgery or irradiation. ApparentIy the chief danger from biopsy today is a misinterpretation of the microscopic picture, and the chief danger in this is that a benign Iesion wiI1 be diagnosed maIignant and the patient wiI1 be subjected to an immediate unnecessary operation or irradiation. NevertheIess, there is a great opportunity for cooperative coordinated and sympathetic investigations among a11 those in the medica and denta professions who are interested in the probIem and responsibIe for the resuIts. I have graduaIIy come to the concIusion that it wouId be very much wiser for any member of the medica and denta professions who feeIs that biopsy shouId be resorted to before any decision as to treatment, not to perform the biopsy unless he is prepared, with his associates, to decide without asking for 331
332
JOSEPH
C. BLOODGOOD
outside heIp, what to do after the sections have been examined. That is, he must be wiIIing to assume the entire responsibiIity of even the immediate frozen section diagnosis. When this member of the medica or denta profession and his immediate associates are unwiIIing to assume a11the responsibiIities of a biopsy, they shouId obtain the advice of the individua1 or group or cIinic to whom they wouId have referred the sections, had a biopsy been performed and they found themseIves unabIe and unwiIIing to decide what to do. I have ampIe evidence to prove the correctness of this statement. The number of individuaIs or diagnostic groups or cIinics who are abIe today to decide, from a microscopic section, what the disease is and what proper treatment shouId be foIIowed, is fortunateIy on the increase, so that any member of the medica or denta profession couId get their advice by teIephone, teIegraph or Ietter aImost immediateIy, and there wouId be no danger from deIay in first finding out the best way to perform the biopsy and whether it shouId be done or not before irradiation, and how it shouId be done. And, in addition, there wouId be IittIe or no danger from deIay of sending the sections to this diagnostician or diagnostic cIinic. The chief mistake made today is performing the biopsy before consuIting the diagnostician or the diagnostic cIinic. The education of the pubIic has proceeded so rapidIy that the reIative number of patients with IocaI Iesions on whom a biopsy must be done has not onIy rapidIy increased, but the difKcuIties of making a correct microscopic diagnosis have muItipIied stiI1 more rapidIy. AI1 surgica1 pathoIogists agree that it is impossibIe today to furnish a suffIcientIy trained and experienced pathoIogist to meet these demands, except in the Iarge cities. Many of the smaIIer hospitaIs in Iarge cities and many of the hospitaIs in smaIIer cities need diagnostic heIp, and there must be biopsies in which there is an interva1 of time between the biopsy and the operation if indicated. There is no diffIcuIty, however, for those who require the heIp of such speciaIIy trained and equipped diagnosticians and
BIOPSY
333
diagnostic chnics, to get this assistance before the biopsy, and to Iearn whether irradiation shouId be tried first, and to obtain the very Iatest views on how the biopsy shouId be performed. As a matter of fact, this method, undoubtedIy the best for the patient and for every one responsibIe for the patient, is resorted to more and more in a most eficient and satisfactory way. However, there are stiI1 too many biopsies performed without these precautionary measures. This correct information has not reached the majority of the medica and denta professions. The education of the peopIe is proceeding so rapidIy, and their response to this correct information is so prompt that the most experienced diagnosticians in the Iargest cIinics are having great diffrcuIties in distinguishing the benign from the malignant in breast tumors, Iesions of bone, pieces of tissue from the cervix, curettings from the uterus, prostatic disease, bIadder tumors, suspicious gaI1 bIadders, indurated areas in the pancreas, pieces of tissue removed by the Iaryngoscope, the bronchoscope, the esophagoscope, the cystoscope; Iymph gIands removed for diagnosis, and practicaIIy wherever a piece of the IocaI Iesion is excised for diagnosis. These borderIine tumors I have been personaIIy observing and recording since Dr. HaIsted and Dr. WeIch turned over to me in 1892 the surgica1 pathoIogy of Dr. HaIsted’s cIinic at Johns Hopkins HospitaI. I have reported on these borderIine tumors in many pubIications, especiaIIy since I g I 3. Previous to 1915 I was rather incIined to the view that naked-eye diagnosis was sufhcient. Now I know that it is not. Recent experience teaches me that it is much safer for the patient to have the diagnosis by two or more pathoIogists than by one, even if the Iatter is the best avaiIabIe. This increasing necessity for the diagnosis by two or more pathoIogists makes it more and more diffrcuIt in operative cIinics which have avaiIabIe onIy one pathoIogist, to meet the demands of this microscopic diagnosis as the number of earIy cases increases. The tremendous change in the necessity for biopsy performed properIy and at the proper
334
JOSEPH
C. BLOODGOOD
time, and the necessity for two or more pathoIogists with special training make it more and more diffIcuIt for any singIe cIinic to meet the demands of today. There is more and more evidence to urge the necessity of ascertaining at once, if possibIe, what the dangers are from a deIay of a few days between a properIy performed biopsy protected if necessary by irradiation preceding and foIIowing it, and some operative. procedure. This wiI1 aIIow microscopic sections to be submitted to a number of diagnosticians or diagnostic cIinics. This is now being done more and more frequentIy throughout this country. So far as my investigations have gone, if the procedures are properIy carried out, there is IittIe if any danger. To repeat, the greatest danger today is that a diagnosis of mahgnancy, erroneousIy made on borderIine tumors, wiII Iead to an unnecessary radicaI operation. There is no harm in giving these doubtfu1 cases irradiation first, and there is no harm in continuing irradiation after an expIoratory biopsy in doubtfu1 and borderIine cases. If operation must uItimateIy foIIow, because the diagnosticians agree on maIignancy, the chances of a permanent cure are apparentIy IittIe, if at aII, affected by this deIay. The bookkeeping of a11 expIoratory incisions and biopsies with the records of the actua1 pathoIogy is, of itseIf, a diffIcuIt procedure, and when the records are properIy made and kept, the foIIow-up offers additiona diffIcuIties, and the most d&c& of a11 is to go over the records from year to year and try to discover if there is any danger in expIoratory incision into a maIignant tumor foIIowed at once by the compIete operation, or any greater danger if there is an interva1 of time between the exploratory incision for biopsy and the necessary operation. There is one thing for a11 of us interested in this probIem to remember. In the beginning there were more frequent expIorations into mahgnancy of a type in which the percentage of cures was very smaI1, or, if there was a biopsy, it consisted in the remova of the mahgnant tumor on the diagnosis of benig-
BIOPSY
335
nancy, and as a ruIe this mahgnant tumor was incompIeteI\removed. In addition, the interva1 of time between the first and second operative procedure was unnecessariIy Iong. Much of the fear of the dangers of biopsy in past years was due more to the maIignancy of the disease than to the danger of the biopsy, and many of the apparent bad resuIts of the biopsy were due not to the biopsy itself, but to the improper resort to this procedure or the improper method pursued. The point that we must remember is that we are to encounter in every IocaIity more and more frequentIy IocaI Iesions in which there must be a microscopic diagnosis before there can be any radica1 operative method or extensive and proIonged irradiation, and, due to the diffIcuIties of distinguishing borderIine Iesions, biopsy with an interva1 of time between the first and second procedure must necessariIy increase in frequency. AI1 of us must make more carefu1 records, be more particuIar in our foIIow-ups, and must constantIy restudy our materia1, so that we may find out exactIy the procedures that are Ieast dangerous in the dissemination of maIignant disease when it must be cut into to remove a piece for microscopic diagnosis. LESIONS
OF
BONE
I seIect this first, because in the majority of maIignant tumors of bone today a biopsy must be performed before the decision as to amputation or resection. As a matter of fact, the majority of sarcomas of bone remaining we11 five years or more after amputation, were subjected to biopsy without irradiation, and there was an interva1 of time of often two weeks between the biopsy and the amputation. In the earIy years the incision into the sarcoma of bone was made without a cautery and the wound was cIosed without the use of chemica1 or therma cauterization. Of the two five-year cures which I reported in 1920, in one there was a biopsy with an interva1 of two weeks before the amputation; the tumor was an osteogenic sarcoma. Drs. Geschickter and CopeIand have made a very carefu1 investigation of the five-year cures which
336
JOSEPH
C. BLOODGOOD
have now accumuIated in the SurgicaI PathoIogicaI Laboratory, and they find that in more than one-haIf of the 70 or more cured cases there had been a biopsy. This evidence is against the danger of a biopsy in Iesions of bone with reference to increasing the IiabiIity to metastasis, but not to the increased danger of IocaI recurrence in the soft-part scar shouId there be resection or curetting. We have sufficient recent evidence that if there is protection by preoperative and postoperative irradiation, there is no danger, except in a pure myxoma, from this expIoration for biopsy, even when the operation consists of resection or curetting onIy. ApparentIy the onIy bone tumor dangerous to expIore is the myxoma, and the greatest danger is when the myxoma has Iiquefied and the Iiquid gets into the soft-part wound. I have reported on this on a number of occasions. There is one exampIe of myxoma without Iiquefaction occupying the Iower end of the femur and its condyIe which was expIored more than seven years ago, the diagnosis of myxosarcoma made from the frozen section, and the immediate curetting of the bony she11 with soIdering irons. This was done at my suggestion by the Iate Dr. Roxey of PortIand, Oregon. This patient is Iiving, without evidence of recurrence and a weII-functioning Iimb at this date. But, to repeat, there was no Iiquefaction of the myxoma. FortunateIy, the majority of authorities on bone tumors agree to the importance of the immediate irradiation of every bone Iesion unIess its x-ray pictures show a definiteIy benign Iesion. I aIso think it wouId be safer, when expIoratory incision has been decided upon in a bone Iesion, to be prepared with eIectric cautery, which I think is better than the eIectric needIe, and, if the Iesion is centra1, to be prepared with soIdering irons and a 50 per cent soIution of zinc chIoride. These are the onIy means of attack on a myxoma that has Iiquefied. The greatest danger of chondroma or chondrosarcoma is to Ieave a piece in the soft-part wound. Today I was Iooking over the x-rays, gross specimens and sections of a patient now Iiving,
BIOPSY
337
more than five years since the amputation of her femur for a chondroma, possibIy a chondrosarcoma of the Iower end of the femur. In this case, there had been three expIoratory incisions with partia1 remova of the tumor. LESIONS
OF
THE
BREAST
Now that the majority of women seek advice within a month after the first symptom caIIing their attention to one or both breasts, the incidence of cancer wiII be Iess than IO per cent in a11 cases, and Iess than 50 per cent in a11 cases subjected to operation. When the breast Iesion is cIinicaIIy maIignant, many surgeons resort to irradiation first. This subject wiII be deaIt with in a Iater paper. When the Iesion of the breast is smaIIer than a twenty-five cent piece and, whether it transiIIuminate cIearIy or darkIy, it shouId be excised, unIess, when cutting down upon it, a typica blue dome is brought readiIy into view. When this happens, the bIue dome shouId be nicked to observe the character of the fluid and the waII of the cyst. When the cyst waII is smooth and the contents cIear or cIoudy it is unnecessary to remove the cyst. SimpIy take a smaI1 piece of the waII of the cyst for frozen section. If there is no bIue dome, then the paIpabIe noduIe shouId be excised with a zone of normaI breast tissue up to the size of a twenty-five cent piece or a IittIe Iarger. When this has been removed, the surgeon pIaces it in the hoIIow of the Ieft hand on a piece of gauze or a toweI, and then bisects it, being carefu1 not to touch it with his own gIoved finger. If the naked-eye appearance and the frozen section are typica of a maIignant Iesion, pIace in the wound an aIcoho1 sponge, or one saturated in 50 per cent zinc chIoride and cIose the skin wound; then proceed at once with the compIete operation for cancer. The majority of authorities agree to this original conception of HaIsted. My recent experience taught me that if the pathoIogist can recognize acute carcinoma, the type that uItimateIy Ieads to cancer en cuirasse, nothing more shouId be done, except excision of the tumor and a zone of uninvoIved breast. The wound shouId be cIosed
JOSEPH
338
C. BLOODGOOD
and the patient subjected to a course of irradiation as quickIy as possibIe. The chances of this patient for comfort during the time she has to Iive are better without the compIete operation. This aIso wiI1 be the subject of another paper. The most diffIcuIt probIem in Iesions of the breast today is what to do when the expIoratory incision removed a microscopicaIIy doubtfu1 tumor. In my experience since 1893 the majority of the microscopicaIIy doubtfu1 tumors of the breast turn out to be benign, no matter what the operative procedure may have been. For this reason, I beIieve it wiI1 be safer to remove the tumor onIy and subject the patient to irradiation whiIe submitting sections of the tumor to a number of trained pathoIogists. UnIess they agree to the diagnosis of maIignancy, the chances are that the tumor is benign and enough has been done. LESIONS
OF
THE
SKIN
There seems no harm in subjecting any Iesion of the skin to a biopsy. But, when the IocaI Iesion can be compIeteIy excised under IocaI anesthesia without mutiIation, nothing is to be gained by cutting out a piece. The ruIe shouId be to remove the entire derma1 Iesion so that the IocaI operation wiI1 be sufficient no matter what the microscope wiI1 show. LESIONS
OF
THE
MUCOUS
MEMBRANE
OF
THE
ORAL
CAVITY
The same ruIe just given for the skin appIies here. But, in the mouth the Iesion may be smaI1, but so situated that its compIete remova is much more diffIcuIt than trying irradiation first. LESIONS
This has been going obtained that it has any an appreciabIe space of piece for diagnosis and
OF
THE
CERVIX
on for years, and no evidence has been eIements of danger, even when there is time between the excision of the smaI1 the irradiation or operation.
BIOPSY LESIONS
OF
THE
BODY
339 OF
THE
UTERUS
There is aIso ampIe evidence in favor of the safety of a curetting biopsy in Iesions invoIving the Iumen of the uterus. There is aIways suffkient time to submit the section to a number of diagnosticians. CONCLUSIONS
The chief danger of a biopsy, whether for a frozen section in the operating room or a fina fuIIy prepared section, is caIIing a benign Iesion maIignant. No one shouId have any diffrcuIty in obtaining advice as to the best thing to do before the biopsy and as to the method of performing the biopsy; aIso as to whether irradiation shouId precede biopsy. The next most important thing is for surgica1 pathoIogists to reaIize and practice that it is safer for the patient when the section, if possibIe, is carefuIIy studied by two or more pathoIogists. When good pathoIogists disagree, the Iesion is usuaIIy benign. When the pubIic is properIy educated to continuous medica care, biopsy wiI1 become a very frequent routine procedure, and there wiI1 usuaIIy be an interva1 of time between the biopsy and the fina treatment. We are a11 beginning to Iearn that a IocaI Iesion or a IocaI symptom needs first a most carefu1 cIinica1 study and a discussion as to whether, when and how a biopsy shouId be performed, and the most important thing of a11is the training of the surgica1 pathoIogist who studies the sections. These great changes are due to the reaction of the inteIIigent pubIic to the educationa campaign of the medica and denta professions which, in this country, has been IargeIy heIped by the American Society for the ControI of Cancer. The two best recent reviews on Biopsy, which practicaIIy cover a11the important Iiterature, are that by HeIIwig (Arch. Pathol., 14: 517-554, Oct. 1932) and that by McGraw and Hartman of the Henry Ford HospitaI (J. A. M. A., IOI : I 205, Oct. 14, 1933). These are important contributions to Biopsy.
340
JOSEPH
C. BLOODCOOD
I also refer my readers to three articIes by me on preoperative irradiation : I. When shouId irradiation with radium or x-ray precede operation or be empIoyed without operation? Ann. Surg., 96: 882-890 (Nov.) 1932. 2. Preoperative irradiation in cases of cancer of the breast with or without biopsy. Ann. Surg., 98: 933-940 (Nov.) 1933. 3. Radiology (May), 1934. I also caI1 attention to the foIIowing articles on Chronic Cystic Mastitis and borderIine breast tumors: In the Arcbiues of Surgery (3: 445-542, Nov., 1921) is my basic contribution on the PathoIogy of Chronic Cystic Mastitis of the FemaIe Breast. There are or ihustrations. In this articIe I give the evidence against any definite reIationship between Chronic Cystic Mastitis in a11 its types (both cystic and non-cystic) to cancer, changing the views that I expressed in Surgery, Gynecology and Obstetrics (3: 721-730, Dec., rgo6), in an articIe entitIed SeniIe Parenchymatous Hypertrophy of the FemaIe Breast, Its ReIation to Cyst Formation and Carcinoma. The Iast articIe on borderIine breast tumors wiI1 be found in the American Journal of Cancer (16: 103-176, Jan., 1932). This has 57 illustrations. Those who propose to attend the meeting of the surgica1 section of the American MedicaI Association in CIeveIand this June shouId read these contributions with the present articIe and prepare themseIves for a further statement on biopsy in breast tumors and the importance of irradiat.ion after the excision of a borderIine breast tumor whiIe waiting for the diagnosis of the consuIting group of pathoIogists. DISCUSSION DR. BRADLEY L. COLEY, New York, N. Y.: In osteogenic sarcoma, whiIe there is a smaI1 percentage of cases in which radiation, in our hands, has accompIished a striking resuIt, the vast majority are very radioresistant. Therefore, it is of great advantage to know with what type of tumor we are deaIing in a given case. We surgeons recognize the dangers of indiscriminate biopsy which pathoIogists have caIIed to our attention, and I beIieve that nowhere is such a procedure more dangerous than in bone tumors. When the biopsy wound is not cIosed in layers without drainage and primary union is not obtained, the resuIts are bad; fungating and infected tumors interfering seriousIy with the future treatment of the cases. We have a method of obtaining biopsy material which was deveIoped IateIy by Dr. Hayes E. Martin of the Head and Neck Department, Memoria1 HospitaI, and which has been extended to other departments of the hospital. We use it frequentIy in bone tumors. Two years ago we* * C&y, Higinbotham and Elks: n.s. 13: No. z, August, x931.
Aspiration
biopsy in bone tumors.
Am. J. Surg.,
BIOPSY reported then
341
on 35 cases in which aspiration
we have
had 75 additiona
cases.
biopsy
was performed,
EIiminating
which were IargeIy head and jaw cases, we now have biopsy
and since
IO
of the first group,
100
cases of aspiration
of bone tumors.
TabIe
I shows the various
was performed
with the positive
types
of tumors
and negative TABLE
I
in which aspiration resu1t.s obtained
biopsy
in each type:
Total
Positive
Negative
Osteogenic sarcoma. Endothelial myeloma. Giant cell tumors. MuItipIe myeIoma. Metastatic. . . InfI ammatory-chronic,
.:
39
28
II
7
7
0
17 8
13 7
4 I
I9
I2 3
7 0
I
0
3 I
Pyogenic .
T.b................. Syphiiis. . Echinococcus. Benign tumor..
2
I
I
0
I
I
0
I
0
I
3 I
100
75
25
Total
Positive
Negative
-
TABLE
II -
-
Skull
Vertebra. Rib. . Sternum. CIavicIe
Scapula. Humerus. Radius. . UIna...... IIium...... Ischium. Sacrum. Femur. Tibia. FibuIa. MetatarsaI, Phalanx
2 I
0
1
7
7
0
0
4
3
1
4
3
I
4
3
I
I3 2
9 2
4 0
2
0
16
10
:
1
1
0
4
3 22
5
27 6
3
I 3 0
4 2
4 2
I
I
0
75
25
100 -
2
0
342
JOSEPH
C. BLOODGOOD
Table II shows the various bones upon which aspiration biopsy was performed. It in&ides broadIy every bone in the body. The frequency corresponds fairIy cIoseIy to the incidence of primary bone tumors in . _ various bones. TABLE III SUMMARY
-
/I
Confirmation
bJo confirmation
&he-
quent course
Set Amputionc:d Biopsy tation Autops? f CZOI
rotaz
Positive aspirations: I. Tumor (a) Complete. (6) Satisfactory. z. Not tumor.. Negative aspirations: I. False positive. 2. False negative.
_ -
6 6 4
6 8 0
3 I I
35 31 9
I 9 ___~ 26
I 2
I 2
3 22
17
8
100
-
Referring to TabIe III, one sees that in 35 cases the diagnosis rendered on aspirated materia1 was compIeteIy satisfactory; by this term we mean that the pathoIogist was abIe to report the specific type of tumor present, e.g., “giant ceI1 tumor” or “metastatic carcinoma,” etc. In 31 other cases, which we have considered as satisfactory, the pathoIogist reported the presence or absence of a tumor and whether or not it was malignant, but was unabIe to cIassify it further, e.g., “ceIIuIar malignant tumor,” “radiosensitive” or some “type of sarcoma possibIy neurogenic.” Here at Ieast was vaIuabIe information which, in conjunction with clinical and radiographic evidence, wouId in most instances permit an accurate diagnosis. Here Iet it be said that even with ampIe gross amounts of tissue removed by operative means we may in unusua1 cases be unabIe to determine the exact type of tumor with greater accuracy than can be done from aspirated materia1. In 9 cases we Iearned from the aspiration that the process was not a tumor. Thus in 75 of the IOO cases we obtained essentiahy vaIuabIe information. The remaining 25 cases, cIassed as negative aspirations, may be divided into two groups: (I) FaIse positive (3 cases) ; and (2) faIse negative (22 cases). The faIse negative cases comprise those in which, though other strong evidence of a tumor existed, stiI1 the materia1 aspirated contained
BIOPSY no tissue upon which a histoIogica1 diagnosis couId be made. These failures mean nothing except a faiIure to obtain aspirated material from the invoIved area or insuffrcient in amount to permit of a pathologica opinion. The smears in these cases were reported as showing onIy bIood, fibrin, muscle, fat, etc., no tumor ceIIs being identified. Those 22 faIse negative cases are not a reflection on the method but a reflection on our abiIity to introduce the needle into the proper pIace in the bone to obtain definite information. I fee1 that as we become more accustomed to the use of the method we wiI1 obtain an even higher percentage of successfu1 aspiration biopsies. The 3 faIse positive cases shouId, perhaps, not be cIassed as negatives, for in each instance a report of a maIignant tumor was made, but subsequent histoIogica1 evidence proved that the type of tumor differed from that reported on the basis of the aspiration. I fee1 that this method has, in our hands, received a suffrcientIy prolonged period of trial to warrant recommending it to others, but with this reservation: It puts an unusua1 demand upon the pathoIogist who is caIIed upon to make a diagnosis from such minute bits of tissue. AIso, there are some types of bone tumor, notabIy, meduhary tumors with an intact cortex, in which it is not appIicabIe. ShouId the aspiration biopsy be unsuccessfu1, one is then abIe to perform a forma1 surgica1 biopsy shouId the indications for it be present. DR. J. SHELTON HORSLEY, Richmond, Va.: When Dr. BIoodgood correIated the x-ray picture and the histologic and clinica findings on the giant ceI1 tumor of bone he took it out of the sarcomas, with which it had been confused, and prevented many unnecessary mutiIating operations. I doubt very much that biopsy of a bone tumor by the exceIIent method Dr. CoIey has so we11 described can be of genera1 use. It requires a great dea1 of ski11 to make a biopsy by this method and, as Dr. CoIey showed in the negative reports, sometimes it is impossibIe to get satisfactory tissue. It aIso pIaces an extra strain upon the pathoIogists and, as Dr. BIoodgood has stated, they are aIready strained too much. The method would be appIicabIe onIy to a very few highIy organized hospitaIs and not in a genera1 way. I rather think that stress upon the proper interpretation of the roentgenogram, and the cIinica1 symptoms, wiI1 usuaIIy be sufficient in the diagnosis of bone tumors. With regard to breast tumors: It is a controversia1 question whether chronic cystic mastitis or Schimmelbusch’s disease causes cancer, but the important thing that is universaIIy agreed upon is to get practitioners to realize that tumors of the mammary gIand must not be massaged but must be sent to the surgeon as soon as possibIe. That is an oId, oId story, but within the Iast week I operated upon a woman who had been treated
344
JOSEPH
C. BLOODGOOD
by a practitioner who gave her some oil to rub on her breast for several weeks before I saw her. I found the axiIIary tissues Ioaded with cancerous Iymph nodes. These sIogans, such as never to massage a tumor of the mammary gIand unIess the. diagnosis of a benign condition is certain (and usuaIIy not then) are so trite that we overlook them ourselves but if we can spread that gospel it wiI1 do much toward cutting down the death rate from cancer of the breast.