The essential evidence respecting a bone tumour is whether it is simple or malignant. The clinical history and condition of the patient at the first examination, though often of vital importance in diagnosis, may contribute little to elucidate the problem. Because of this and because the histology of normal tissues is characteristic, while pathology is associated with considerable change in the cellular and intercellular structure, we turned to histology for conclusive evidence. A widespread belief prevails in the infallibility of this evidence. Indeed, so firmly is this belief held that, if the subsequent history of the case differs from the forecast given, it is the pathologist, however eminent, who is blamed for the erroneous interpretation, rather than the vagaries of the histological material. Consequently, certain leading authorities hold that biopsy affords a means of “fully proving” the nature of bone tumours and always resort to biopsy prior to any major surgical measures, notwithstanding Ewing's advice that “few surgeons realise the limitations in the histological diagnosis of bone tumours and the conditions which simulate or accompany them.” An examination of the reports on the histology of bone tumours reveals the indecision which the appearances produce. For, whereas in the descriptions of normal tissues we see the use of definite terms, such as myxomatous, fibrous, cartilaginous, or osseous, in the description of pathological tissue we see the indecisive terms mucoid, fibroid, chondroid, osteoid, mucofibroid, fibrochondroid, chondrosteoid, etc., terms which permit of considerable latitude of expression by different observers. The medical student is usually taught his pathology, histology, and radiology from well established lesions and does not realise how closely simple and malignant lesions simulate one another in the early and, indeed, in some cases, in the late stages. Biopsy involves the risks of anaesthesia, surgical exploration, and all that it means in additional damage, dispersal of tumour cells, destruction of the scaffolding on which repair may be built up, etc., and the mental and physical pain associated with it—risks sometimes resulting in the death of the patient with a simple lesion, which could possibly be regarded as negligible or justifiable if the evidence so obtained were reliable. Consequently, as I have pointed out more fully elsewhere,1 we ought before biopsy to satisfy ourselves with the answers to several questions: (1) Can the findings of biopsy be relied upon? (2) How should the biopsy be performed—by needling, punch, or real exposure and inspection? (3) Does any form of biopsy permit us to watch sufficiently the evolution of a tumour to establish its nature? (4) Will biopsy enable us to get an early correct diagnosis?
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