New Series Vo!. I, No. 2 American Journa l of Surgery

THE IMPORTANCE OF PATHOLOGY IN T H E PRACTICE OF SURGERY*

• JOSEPH SCHWARTZ, M.D.

NEW YORK

[From the surgical service and pathoIogicaI Iaboratory of Lebanon Hospital]

N O other branch of medicine affords such an excellent opportuni ty to s tudy pathologyin the Iivingas does

surgery. Inasmuch as this specialty deals in the main with the repair of pathologicaI conditions it behooves the surgeon to be famiIiar with the more common pathologi- Cal Iesions so tha t he may be abIe to iden- t ify and correct such defects with greater proficiency. • The first prerequisite of a surgeon should

be a thorough understanding of the patho- logical nature of the surgicaI conditions with which he has to deal. The surgeon should be cognizant of the remote possi- bilities tha t may follow apparent ly insignif- icant surgical lesions. More than a superficial knowledge of the pathology of surgical diseases is necessary tbr the great hazards encountered in some cases while performing abdominal explorations. Acci- dental surgical findings where the lesions are congenital or acquired sometimes pre- sent themseIves to the unsuspecting sur- geon and only one experienced in pathoIogy wiII intelligently manage the presenting lesions with best resuIts.

A maIe, aged 65, was expIored for an abdomi- naI tumor in the right Iumbar region. After careful examination it was recognized that the tumor was a cystic kidney. With the knowl- edge that this condition is usuaiIy biIateraI further examination showed that the Ieft kid- ney was aIso poIycystie. In the hands of the inexperienced the right kidney might have been removed.

I t is most discouraging when we are reminded tha t approximately forty per cent of cases are incorrectly diagnosed as proven by operation or post-mortem inves- tigation. Largely contributing to such deficiency in recognizing surgical diseases

is the striking iack of autopsies in most of our hospitaI cases. Pos t -mor tem studies wouId enable the surgeon to familiarize himseIf with the existing Iesions and coor- dinate them with clinical manifestations; they would aIso expose mistakes in diag- nosis, errors in judgment and technique.

Not infrequently one encounters a surgi- cal case whose clinical features are too obscure to permit an accurate diagnosis. Often an exploratory laparotomy is inevi- table when it is our only means of revealing the nature of the lesion. Even in the face of an opened peritoneal cavity one sometimes has to delay his final opinion until the autopsy owing to marked pathological changes. If a necropsy is omit ted the case remains shrouded in obscurity.

A female, aged 4o, came to Lebanon Hospital presenting abdominal ascites and irregular abdominal masses. Tuberculous peritonitis and maIignant new growth were considered, the Iatter being favored. Assuming the diagno- sis of a malignant growth to be correct, where was the origin? The patient was expIored. Serosanguinous fluid was found; the intestines were matted together by dense growths; the liver showed extensive metastases; small growths were present on the peritoneum. The condition was unquestionably maIignant as proven by biopsy. The seat of origin was difficult to decide aIthough we were inclined to believe it was in one of the ovaries. Only an autopsy would have decided the point in question.

A femaIe, aged 5o, was suddenIy seized with abdominaI pain and went into collapse. There was a ,large mass in the left lower quadrant and lumbar region. The patient appeared to have an internal hemorrhage, and was thought to have a twisted ovarian cyst. Operation discIosed a large retroperitoneaI tumor prob- ably of renaI origin. Autopsy reveaIed a large

* Read before the Bronx SurglcaI Society, March ~4, 1926.

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9 6 A m e r i c a n J . . . . . . 1 of Surgery Schwartz--SurgicaI Pathology AUGUST, I926

hypernephroma of the Ieft kidney in which there had occurred a profuse hemorrhage.

One can readiIy appreciate from the above eases the difficulty of accurate recog- nition of diseases often even after expIora- tion. In such type of cases, as weI[ as in others where death ensues, we shouId particularIy avail ourselves of every oppor- tun i ty to s tudy pathoIogicaI Iesions b y means of autopsy.

The great bugbear of every surgeon is tha t a fatal outcome may ensue in a case expected to survive, especialIy where the Iesion has apparentIy been very slight. If death does occur he may Iook with suspicion upon his technique or perhaps feeI tha t he may have overIooked some other pathological condition. Often onIy by a thorough autopsy will there be found some hidden cause for the death.

I have in mind a chiId seven months oId who was operated upon for intussusception of the iIeo-cecaI variety. Reduction was rapid and not difficuIt. FoIIowing the operation the child did weII for two days when it suddenIy became worse and died. It was thought then that death resuIted from the usuaI shock and toxemia associ- ated with such condition. Autopsy reveaIed a stranguIated gangrenous Ioop of smalI intes- tine due to a voIvuIus. This was entireIy inde- pendent of the intussusception which had been properly managed.

An infant one week oId was given 25 e.e. of whole bIood through the anterior fontanelIe. No incompatabiIity of bIoods existed. About one hour after the injection the chiId died. Suspicion was aroused in the minds of those seeing the child that death was from an intra- craniaI hemorrhage due to the transfusion. This, however, was not present at the autopsy.

Another infant who was given a number of saline solution injections in a period of one week through the anterior fontaneIIe died after the fifth injection. Here a brain hemorrhage was found due to a perforation of the sinus.

A femaIe, aged 36, who was delivered by Cesa- rean section because of a dystocia due to a uterine fibroid, died three days after the opera- tion. CIinicaIIy she presented signs of pneumo- nia thought to Be entireIy responsible for her death; beginning peritonitis was aIso suspected.

At au topsy there was also found a diffuse suppurative pIastic peritonitis caused by a degenerated infected fibroid which had per- forated. Without a post-mortem examination the peritonitis wouId undoubtedIy have been attributed to fauIty technique.

A female, aged 35, was admitted to Lebanon Hospital in coma which came on very suddenIy after she compIained of slight abdominaI pain. Those who saw her prior to admission ventured the opinion of a cerebral accident. At autopsy a hemorrhagic pancreatitis was found.

A child 3 years oId sustained a crushing injury of the right forearm necessitating ampu- tation because of gas bacillus infection. An injury to the Iung was suspected. There was aIso some suggestion of an abdominal injury the nature of which couId not be determined clini- cally. The child finaIIy succumbed. The autopsy discIosed a ruptured Ieft Iung with a hemo- thorax containing hemolytic streptococci, and a ruptured spIeen which had stopped bIeeding and about which there was an abscess. This case is very instructive because it proves that a ruptured viscus, espeeiaIIy the spleen, may sometimes stop bleeding spontaneously and thus make operative interference unnecessary.

A femaIe, aged 5o, was subject to repeated attacks of dyspnea and ~yanosis. The condition reponsibIe was thought to be a substernal thy- roid. An imperative tracheotomy was done but without success for reasons discIosed post mortem. Then we found a Iarge spindIe-ceII sarcoma almost cIosing off the trachea entireIy in the superior mediastinum.

The cases cited above are only a few chosen to emphasize the value and need of post -mortem study. We must bear in mind tha t b y such means only can we solve cases whose recognition cannot be established clini~alIy. No t infrequently a post-operat ive death cannot Be explained b y autopsy.

Pos t -mor tem investigation should not be deIegated to one inexperienced, who may confuse rather than enlighten the situation. Where possible the surgeon himself or some competent member of his staff shouId personaIIy witness the autopsy, so tha t he may be impressed with the findings which may perhaps reveaI

New Series Vol. I, No. Schwartz--Surgical Pathology A . . . . ican J ...... ~ of Surgery 97

errors in diagnosis o r technique. I t would aIso help him to interpret similar symptoms on the basis of existing pathology.

CulIen, in an editorial in Surgery, Gynecology and Obstetrics, November, i925, stated that it wouId be a great comfort to the surgeons to have a general pathoIo- gist on hand at all times to advise him in obscure conditions. He highIy recommends a training in pathoIogy prior to entering the pra, ctice of surgery.

A knowledge of surgicaI pathoIogy is of the greatest importance, for without it the operator cannot exercise the proper judgment and skill in coping with surgicaI conditions. This is of prime importance in surgery of the abdomen. The benign lesions of the stomach must be differenti- ated from the malignant. If the Iatter is present the extent of involvement and the presence of any visceral metastases must be recognized.

A case in point is a maIe, aged 35, who was operated upon for a suspected duodenaI uIeer or diverticuIum. At the operation no such Iesion existed. There were Iarge, hard, discrete masses in the mesentery of the smalI intestine apparentIy Iarge Iymphatic gIands. The diagno- sis of Hodgkins' disease was immediateIy entertained and Iater proven at autopsy.

Carcinoid tumors of the small intestine and appendix form a very interesting type of tumor, often considered maIignant by those unfamiliar with it when in the ma- jority of instances it proves benign. The Iack of such knowIedge concerning their behavior often brings an unfavorable prognosis from the surgeon and much to his surprise the pat ient survives the operation without recurrence.

In a diseased biliary system one must conceive of the remote effects on IocaI or more distant organs. One of our patients was op4rated upon for cholelithiasis when, m addition, it was found tha t a fistula existed between the ga l lbIadder and the duodenum. Its non,recognition in the hands of the inexperienced surgicaI pathoI- ogist wouId undoubtedIy have Ied to

meddlesome surgery. On many occasions {he pancreas, because of its hardness secondary to an infected biliary tract, is considered maIignant. Secondary changes in the Iiver are very common as a result of a diseased biIe tract.

In the femaIe pelvis one frequently finds pathoIogic changes tha t demand accurate definition before operative measures are instituted. In the removal of a papillary cystadenoma or adenocarcinoma of the ovary it is important to exercise alI necessary skiII to prevent rupture, for if tha t occurs the papiIIary growths implant themselves readily on the peri toneum with an unfavorable outlook.

In the management of breast tumors one cannot always telI with certainty the character of the growth bu t the experi- enced surgical pathoIogist will have a decided advantage in determining such questions.

A femaIe, aged 4o, had an irreguIar mass in her Ieft breast and no paipabIe regionaI gIands. It simulated maIignant growth but because of the history of trauma and the character of the mass, it was thought to be traumatic fat necro- sis. The opinion was confirmed by its gross and microscopic appearance after removaI. No radicaI amputation was necessary.

The microscopic s tudy of pathological materiaI seems unnecessary to some sur- geons and is very frequentIy negIected in view of an apparent gross pathological diagnosis. We have often received in the laboratory innocent-Iooking specimens which after careful microscopic s tudy yieIded evidence of maIignancy. Appar- ently benign Iesions shouId not be regarded IightIy unless the microscopist verifies their benign character.

In cIosing, I reaIize tha t these facts are very eIementary and are undoubtedIy familiar. Nevertheless they deserve repe- tition because of their extreme impor- tance to the surgeon. A knowIedge of pathoIogy not onIy opens to a broader view of surgical diseases bu t also heIps to maintain a high surgical standard.