Autopsy Table Research Articles

Bone Metastasis in Carcinoma of the Stomach: Report of Five Cases

Though carcinoma of the stomach is one of the most common malignant tumors of adult life, bony metastases from this source are infrequent. The total number of cases showing bone involvement is variously stated as from 1.0 to 22.0 per cent of the total (Schinz, Fraenkel) though the usual figure is under 6 per cent (Muller, von Glahn, Colwell, Symmers). The reported incidence depends obviously upon whether the author9s observations have been made at the autopsy table or roentgenographically and, in either case, upon the thoroughness of the search. In any event, metastatic involvement of the bones is certainly relatively low in gastric cancer as compared, for example, to that in carcinoma of the breast and prostate. We have found in the literature 143 apparently authentic cases, with a case or two of direct invasion and one doubtful case. To these we add three cases with roentgen evidence of osseous involvement and two found at autopsy, bringing the total number to 148.

GROWTH FACTOR FROM ANTERIOR PITUITARY

To the Editor:— I take this opportunity to add my word of commendation to the thousands which I know you have already received on the leading editorial, Antihormones, inThe Journal, August 18. Dr. Cushing undoubtedly issued a sound note of warning against the indiscriminate use of endocrine products and I am pleased to see you again warning the doctors about so-called isolated active principles. I have in mind chiefly or particularly the extract of the anterior lobe of the pituitary, which I believe is now known to produce a growth factor. My research on cancer cases at the autopsy table has led me to believe that in this condition the anterior lobe is hyperactive. For this reason I cannot help but feel that you have shown the part of wisdom in proclaiming your announcement.

An Analysis of a Group of Primary Newgrowths of the Lungs, Treated with Deep X-Ray Therapy

This analysis has to do with 27 cases. The diagnosis in each case is based on the histologic study of tissue removed by means of the bronchoscope in the hands of Dr. Jackson or Dr. Clerf, and in one case by Dr. Tucker—by surgical means or at the autopsy table. Was-sermann and Kahn tests were made in all of the cases and were found to be positive in one. The histologic studies were made by Dr. Crawford, pathologist at the Jefferson Hospital. There was clinical and roentgenographic evidence to support the histologic diagnosis, which in each instance was malignant. More specifically, the histologic diagnosis was: carcinoma in 11; squamous-cell carcinoma in 6; carcinoma (undifferentiated) in 4; adenocarcinoma in 3; endothelioma in 1; epithelioma in 1, and one case diagnosed carcinoma from a gland removed surgically from the anterior chest wall. Crawford and Clerf have restudied all of these cases and others in the past year and have reclassified them. As a result of this review, the histologic diagnoses of th...

LIPOIDS AND LIPOID DISEASES

We present here a study of the lipoid content of the various tissues of the body in a case of Schuller-Christian's disease together with a review and discussion of the literature to date. Because of the severe anemia encountered in this case we include a parallel study on the tissue of a child of about the same age with similar anemia due to another cause. It was our idea that the latter might in a way act as a control. It has been our hope that should a case of accident come to autopsy we could present our own normal figures. This opportunity has not presented itself. METHODS The material was obtained from the autopsy table as soon as possible. All extraneous blood and tissue were carefully removed. None of the tissue was perfused. It was ground in a meat grinder and weighed. It was then placed in 95 per

CIRCULATION OF THE HEAD AND NECK OF THE FEMUR

The study here reported was made of seventy-nine cases of fracture of the hip. An analysis of the age, type of fracture, roentgen observations, character of treatment and end-result has been made. All of the intracapsular fractures were treated by the Whitman abduction treatment. Nonunion resulted in four cases in which Whitman's reconstruction was performed. These cases afforded an opportunity for both gross and microscopic studies of the removed ligamentum teres and femoral heads, as well as examination of the area of nonunion in each instance. Considerable material has also been obtained at the autopsy table and from the dissecting room for further study in regard to the source of the blood supply to the head and neck of the femur. Observations were also made in reference to the part the ligamentum teres had to play in carrying nourishment to the femoral head. It was hoped that information gained from

Roentgen Diagnosis and Treatment of Thymomata

PRIMARY tumors of the thymus, as a group, have not been recognized clinically in as large numbers, in the past, as they should have been if all the diagnostic measures had been employed. A perusal of the literature of this subject discloses the fact that a large percentage of the cases came to the autopsy table without a correct diagnosis having been made and many of the cases had not even had a roentgenographic study of the chest. Much of the literature is concerned with discussion of the pathology of these tumors, especially as to the origin of the small lymphocyte-like cells found in the parenchyma. This uncertainty as to the exact origin of these cells has led to the word “thymoma” being employed to designate certain tumors which in general resemble lymphosarcomata. These tumors are relatively uncommon but apparently not so rare as the literature would indicate. Approximately one hundred cases of primary thymic tumors have been reported, of which less than twenty were carcinomata and practically all the remainder were sarcomata. Anatomy The thymus is a paired organ arising from the third bronchial clefts. It occupies the anterior and superior mediastinum and varies in size according to the age and general condition of the health. It may be so large as to fill the available space between the pleural sacs laterally, the sternum anteriorly, and the pericardium and great vessels posteriorly. On the other hand, it may be so small that it is found with difficulty at the postmortem table. Its shape is determined by its size and by the structures with which it is in intimate contact. There is a fibrous capsule which sends septa into the substance of the gland, thus dividing it into lobules which are, in turn, subdivided into follicles. These follicles consist of medulla and cortex. The structure of the cortex resembles lymph gland structure, except that the reticulum instead of being fibrous is syncytial. The spaces of the reticulum are crowded with lymphocytes. The medulla resembles the cortex, but the reticulum is coarser and contains cell nests, the concentric corpuscles of Hassall. Pathology Primary thymic tumors, according to Ewing (1), may be classified as follows: (1) Lymphosarcoma or thymoma, composed of a diffuse growth of round, polyhedral, and giant cells. The chief source of this tumor is probably the reticulum cell, but lymphocytes are often present in abundance. (2) Carcinoma arising from the reticulum cells. (3) To these may be added very rare and somewhat questionable cases of tumors attributed to the stroma and called spindle-cell or myxosarcoma. When the chest is opened at the postmortem table a mass is seen occupying the region of the thymus. This may be round or triangular in shape, lying in the anterior mediastinum, and is usually yellowish or grayish in color. It may be encapsulated but is frequently adherent to the sternum and surrounding organs, and may invade the pericardium, pleura, lungs, trachea, and glands.

PRIMARY CARCINOMA OF THE URETER

The rarity of primary neoplasms of the ureter and the great difficulties offered to accurate diagnosis, especially in the case presented here, has stimulated me to review the reported cases and to present data which, I hope, will aid in the early diagnosis of this condition. Early treatment is necessary to save the lives of these patients, since these tumors have widespread and rather early metastases. There is no symptomatology that is of any special aid in the diagnosis of this condition. A review of the literature on this subject discloses that the diagnosis of fifteen of these cases was made at the autopsy table; in only eight or nine clinical cases was the true condition suspected, and in only three cases was the diagnosis made before operation. The first case report, that of Wiesing and Blix, 1 was made in 1878, and not until that of Davey, 2 in

MORPHOLOGICAL CHANGES IN THE ENDOCRINE GLANDS IN MONGOLIAN IDIOCY WITH REPORT OF TWO CASES

The etiology of mongolian idiocy is as much a mooted point today as it was when the condition was originally described by Langdon-Down (1). The possibility of an endocrine genesis has been the subject of much investigation and discussion, especially with reference to disturbance of the thyroid gland and, to a lesser extent, of the pituitary. This relationship has been suggested on the basis of both clinical association with symptoms referable to dysfunction of the thyroid, numerous examples of which are in the literature (2), and of histo-pathological alteration in these glands as demonstrated on the autopsy table. The literature on mongolian idiocy as a whole is voluminous but that portion dealing with reports of post-mortem examination of the endocrine glands is comparatively scant. As with most endocrine problems at the present time, the findings have given rise to contradictory interpretations. Siegert (3) made an intensive study of the literature in 1910 and reported that in the majority of instances normal findings were found on both macroscopical and microscopical examination. He personally feels, however, that in the majority of cases of mongolian idiocy there is at certain times a disturbance of function of the thyroid gland independent of the presence of demonstrable manifestations of hypothyroidism or athyrosis. Kassowitz (4) is also of the opinion that all cases of mongolianism show at times thyroid changes.

THE SO-CALLED HOUR-GLASS TUMORS OF THE SPINE

The experience some years ago of finding at operation on a paraplegic patient a circumscribed extradural spinal tumor, the narrowed pedicle of which proceeded through an enlarged intervertebral foramen to be continuous with a larger growth in the posterior mediastinum, has led to a continued interest in the so-called hour-glass or dumb-bell tumors involving the spinal cord. My first patient was seen and operated on in 1916, and only recently have two others come under my observation. To the comparatively few who have personally observed them at the operating or autopsy table, these tumors are well known; to the great majority of physicians and surgeons they are apparently quite unknown. They have a very general interest, for while they implicate the cord eventually and are therefore more often seen by the neurologist and neurosurgeon, their paravertebral portions may present in the neck or back to confuse the general surgeon just

The Internist and Radiology

NATURALLY, it is with a certain trepidation that an internist ventures to address such a scientific body as this, concerned, as it chiefly is, with a specialty far afield from the routine endeavors of the practitioner of medicine. The daily work of the medical man concerns itself much with roentgenology ; in fact, more and more continuously, but this contact between internist and radiologist is hazy and indefinite. It consists largely of the blind acceptance by the internist of the statements of the roentgenologist as to the proper diagnosis of films, and concerns itself not at all with thoughts of technic or details of method. It is for this reason, then, that I hesitate to venture to express to the members of an organization like the Radiological Society of North America my concepts and ideas about a highly specialized branch of medicine. On the other hand, because of this very fact—the high degree of specialization of your branch of medicine, together with the more or less isolation of the roentgenologic specialty, removed from close contact with medicine, as the internist views his profession—it might be well for me to discuss the limitations of roentgenology as they appear to the medical man as a diagnostic method solely, and dismiss from consideration any mention of radiotherapy. Bear in mind that the position of the roentgenologist in the world of medicine is rather anomalous. He is the only diagnostician in medicine who depends upon physical methods alone to gain his objective, in contrast to the man who must employ biologic and chemic, inductive and deductive measures in order to make an anatomic and functional diagnosis—an anatomic diagnosis which never attains the high degree of exactitude of that of the roentgenologist. He is the only diagnostician who depends solely on his eyes and does not have to call upon the auxiliary special senses, notably of touch and hearing. He is primarily a physicist, secondarily a physician, one who is by knowledge fitted to examine and to treat the sick. He is interested in the manifestation of disease as seen on a film and produced by physical methods, but not in the changes incident to disease that are observed and sensed when standing by the autopsy table. These observations are trite and obvious. They are, for the most part, recognized and appreciated by the body roentgenologic, but they are not taken into consideration by the medical profession, which everywhere seems willing to accept the word of the radiologist as dogma and proven fact. It seems to me that the share contributed by the roentgenologist toward furthering the misconception of the all-embracing authority of the roentgen film lies for the most part in his endeavor to make diagnoses, functional in character. The best example that we can mention is that observed in the usual report, such as is submitted after a complete gastrointestinal examination.

Dilatation of the ureter in the male: Autopsy findings

D ILATATION of the ureter ‘1~3s first described by Cruveilhier, 1 who found it women who died the 13tter months of pregnancy or just 3 ftcr deli\.ery. Dcsgr:mges,” 1822, described h?:drourctcrosis of large dimension due to ;I xx c;lses of h>.dronephrosis which abdomin:il tumor had been caused by the renaI distension. In several instances the c:tuse of the nephrectasis was not nscertnined, but 26 cases the obstruction \V;G found situntcd the ureter, and 3 others calculus \vns present the renal pel\+. Structure of the ureter has been described 1~~ hloi-ris, Euart,’ Galliard,” Kroner,” ancl Avro1les.T F. S. 1Vatsons was the first i n Anicric:, (,I@;) to describe uretern1 stricture. F:trlon,!) Kelly, lo Fenger, I’ Hunncr’~ and others have made similar c)bser\~ations. \l’ith the :ld\rent of the cystoscope and the injection of ;w opaque solution” into t hc ureter :Ind kidne): peIvis, the diagnosis of ureter:\1 ;1 bnormnlity is frequently made. O\\ing to the large number of cIinicn1 studies xntl the lnck of studies on the urinar-Jlr:1ct :It the autopsy table, the following in estig!-ntion bins undertaken.

The Roentgen Treatment of Leukemias

BY leukemia is meant a condition in which there is extensive proliferation of the leukopoietic tissues of the body, either lymphadenoid or myeloid, with the appearance in the blood of white blood cells not normally present. There is, usually, an increase in the number of white cells; this, however, is not the absolute rule. In 1845, Virchow recognized the leukemic states at the autopsy table: shortly afterward Vogel recognized the disease during life. Since the work of these pioneers our ideas of the leukemias have undergone remarkable development. During the past years we have learned to distinguish between leukocytosis and leukemia. This differentiation has not been made on the number of white cells present, as there are often cases with a leukocytosis of 100,000 white cells per c.mm. and leukemias showing only 50,000 white cells. The usual leukemia as a rule shows a white count far in excess of 50,000. Another important step in the diagnosis of leukemia was the recognition of the qualitative deviations in the white cells, which was of far greater aid in differentiation than the quantitative changes in the total count. Ehrlich, by means of specially stained smears, introduced the differential blood count, which was an important factor in diagnosing these difficult blood diseases. It was soon found that in certain cases of leukemia the lymphoid cells predominated, while in others the myeloid cells were more common. Following this discovery it was thought for a time that the presence of myelocytes was absolute evidence of leukemia; later on, the non-leukemic myelocytes of bone marrow carcinosis and anemia pseudoleukernica infantum were recognized. Through clinical and autopsy studies, it has been demonstrated that proliferation of either the lymphoid or myeloid tissues similar to those that occur in the leukemias may take place without the appearance of immature cells in the blood. In the majority of cases, a diagnosis can be made from the differential count of the white cells alone; in some cases, however, the blood picture in itself is insufficient for a diagnosis. In arriving at a diagnosis no one method or sign should be depended upon as conclusive. Each patient should be studied by all available methods before drawing our final conelusion. It was thought by some, on account of the enlarged spleen in some cases of leukemia, that leukemia is splenogenous in origin; this we know is not true and that the leukemias are divided into two main groups, namely, those of lymphadenoid origin and those of myeloid origin. Leukemia is not a disease of anyone organ, but a condition that is widespread throughout the body. In certain patients, the disease may attack the lymphadenoid tissues all through the body, while in others the disease may show a predilection for the myeloid tissues of the marrow of the various bones of the body.

Applied Pathology of Pulmonary Tuberculosis

OUR greatest knowledge of the pathogenesis and pathology of pulmonary tuberculosis has come from two sources: postmortem studies and animal experimentation. The most instructive study has been the artificial production of the disease in the animal. In our human patients we have been able to study the actual changes wrought in the lungs by the tubercle bacillus only by the indirect signs elicited by the clinical examination of the patient. We have realized our shortcomings and errors in translating physical signs into pathological changes within the lungs. Therefore we have seized upon animal experimentation to teach us more, since here we can control our material and make direct observations of the lungs at will. We have learned and are learning much from the observation of animals; it behooves us as well to view each human patient as a source of scientific knowledge. Armed with the knowledge gained from experimental studies, the pathologist lays bare the dead lungs on the autopsy table and tells us what ...

ALBUMINURIA; ITS PROGNOSTIC VALUE IN CHRONIC NEPHRITIS.

The mass of evidence which has come to us of late, from the autopsy table, shows conclusively that chronic nephritis exists and is an unrecognized cause of death in a proportion of cases far beyond ordinary belief, and the comparison of carefully kept records of cases before death with autopsy findings shows that little reliance can be placed on the mere urinary examination, either positive or negative, as a means of absolute diagnosis or prognosis of Bright's disease. It will be the purpose of these notes to show that the result of the ordinary examinations of the urine, either in our offices or laboratories, are of little if any value in very many cases, from a diagnostic or prognostic standpoint, and that we are forced upon the very varied and numerous clinical manifestations and the absolute toxicity of the urine as offering the best and safest means of diagnosis. That

On the preparation of potassium and sodium

During autopsies, an open oscillating saw produces large quantities of respirable bonedust, which is able to carry microbes over several metres. Experiments were done using a modified (open) undulation saw (spray tube to moisten the saw-blade with water). Saw-dust was asservated with culture media. Colonies were identified macroscopically. Microbes in the air were quantified (per unit of time). A remarkable reduction of saw-dust is done by an integrated spray tube using water. There remains a contamination at the head of the autopsy table in the level of the table-top. We found a complete decontamination 150 cm above the floor. No spreading of particles carrying microbes was seen over distances of more than 1.5 m. The risk of an airborne infection is minimal when using a manual saw (absence of grinding-dust). The modified type of an ‘oscillating saw with a spray-tube’ may be considered a practicable compromise between a manual saw and an unprotected undulation saw. It is necessary to complete the precautions against airborne infections by breath masks and safety-goggles.