On the Diagnosis of Tumors, with Especial Reference to the Evil Results of Overconfidence and Delay

MAURICE H. RICHARDSON
1907 Boston Medical and Surgical Journal  
The frequent occurrence of diseases previously regarded as rare, soon after attention has been called to their possible existence, has been remarked by most observers. It is often said that an unusual case in practice is immediately followed by one or more similar cases. For example, a splenic leukemia, seen one day, is followed by another the next; or an extrauterine pregnancy, operated on in the morning, is followed by another in the afternoon. Such occurrences are, of course, purely
more » ... se, purely accidental. A disease accurately described for the first time seems thereby to be put immediately upon the increase; but the explanation of the fact lies, as we know, in the increased attention called to the subject, the added knowledge which makes the lesion suspected, and the careful search for the disease by the general practitioner. With the demonstration that the vermiform appendix is the cause of most symptoms in the right iliac fossa, the number of cases of appendicitis has increased beyond all conception of the early days. The changes in the pancreas owing to gallstones, and relieved by cholecystostomy and drainage, have been noted with increasing frequency. So it is with many clinical problems. The moment a question arises, conditions seem also to arise as if for the direct object of solving that question. Ten or fifteen years ago the subject of actinomycosis, for example, was brought up by Dr. C. A. Porter in connection with chronic inflammatory diseases of the lower jaw, previously treated as alveolar abscess with dead bone. This disease had hardly, in my recollection, been mentioned, and was by many of the staff myself for onenot known even by name. Cases began immediately to be discovered, and with increasing frequency. Through the general interest excited by the studies of Dr. Wright and through the eager search made by the staff, the disease has now been demonstrated in different parts of the body. In one year I found three cases of abdominal aotinomycosis, all so strongly resembling malignant disease that the diagnosis of cancer seemed the most plausible one. The possible presence of this lesion is now considered in the diagnosis of many if not most doubtful tumors, especially in connection with the alimentary tract. The discovery of new and easily demonstrable facts has added such strength to the diagnosis of many previously obscure conditions, that they are no longer obscure. Contributions to the pathology of tumors, like the demonstration of the relations of the ray fungus to intestinal growths, or of the influence of gallstones in producing chronic inflammations resembling new *Read before the Obstetrical Society of Boston, Oct. 23, 1906. growths of the pancreas, have cleared up many previously obscure questions. The etiology of tumors is better understood, or rather is a little less unknown or unsuspected. The influence which new growths exert in the very beginning of their offending, and the gross changes which they undergo in their early life history, are, as time goes by, better and better predicted and understood. The tumors which may be left with comparative safety and those which may not, whatever the pathological report may be, are within reasonably accurate recognition. Fewer errors are made previous to operation, and fewer unnecessary operations are performed. The diagnosis of tumors is, nevertheless, uncertain, even at the present day and in the hands of the most experienced men. Many unnecessary, not to say unjustifiable, operations are performed, while many imperative ones are withheld. The decision for or against operation must depend in most cases upon the educated touch; but many tumors are so deeply seated that it is difficult, if not impossible, to feel them. In all cases the final diagnosis after exposure of the tumor depends largely upon the sense of touch. The diagnosis of inaccessible tumors depends exclusively upon the history and the general examination. Accurate demonstration necessitates the exploratory operation which in such regions as the deep epigastric is easy and safe, and which may be followed immediately by the radical operation. In other anatomical areas, the brain, for example, the exploration is itself so dangerous that the removal of the tumor does not add greatly to the risk. Indeed, the early discovery and prompt removal of ¡i tumor from the cortex is less destructive to cerebral tissues than the laborious and extensive search for something which perhaps does not exist. But however absorbing may be our interest in the new growths of the brain, spinal cord, the pleura, pericardium, lungs and mediastinum, tumors situated in these regions do not permit much more than a shrewd guess as to their existence; much less do they permit a reasonably accurate opinion as to their nature. Such tumors are beyond the scope of this paper, in which I wish to consider mainly the common and accessible tumors. Since reading in Atlanta in 1903 upon practically the same subject as that considered in this paper, I have been impressed more deeply than ever by its importance, for in the three years which have elapsed since then I have seen the evils which follow the overconfident diagnosis, whether of malignancy or of benignancy. Clinical records are crowded with the histories of tumors in their early and operable stages and their worse than useless treatment by " absorbents," " counter-irritants," trypsin and other newly-discovered and much-advertised " scientific " methods of sure cure. In some instances, but too few to be in the aggregate of serious moment, my operative records contain the pathologist's report of benignancy when the operative diagnosis read malignancy. Even in those cases, however, like pyloric stenosis of
doi:10.1056/nejm190703071561001 fatcat:qtemkqs25zfytpcgtcpz6yb3by