THE EARLY DIAGNOSIS OF MALIGNANT 
GROWTHS. 
By J. COLLINS WARREN, M.D., 
OF BOSTON. THE EARLY DIAGNOSIS OF MALIGNANT 
GROWTHS. 
By J. COLLINS WARREN, M.D., 
OF BOSTON. 
[Read before the American Surgical Association, May, 1889.] 
The great impulse which antiseptic treatment has given to 
operative surgery has brought with it renewed courage to the sur- 
geon in the struggle with malignant disease. Many forms of 
cancer which have formerly been regarded as beyond the reach 
of surgical interference, are now being subjected to new methods 
of treatment, and the operations devised for their eradication are 
furnishing materials for statistics replete with interest. Although 
we are not sufficiently familiar with the nature of this formidable 
disease to authorize the hope that any royal road to that desira- 
ble goal—a cure for cancer—is likely to be discovered, there is 
reasonable ground for hope that the more radical operations of 
to-day will help to lift the treatment of this disease out of the 
slough of despondency in which it has been buried. 
It is hardly necessary for me to urge upon such an audience 
as this the importance of an early recognition of the disease as 
an important aid to surgical treatment, and yet it seems to me 
that this branch of the subject has not received the attention 
that it should in the light of modern surgery. Few surgeons 
are free to admit that their powers of diagnosis are unequal to 
the task, but the number of cases of cancer which are kept 
under observation until the disease has reached that stage which 
places it beyond the reach of the knife would present a formid- 
able list, and one far from flattering to our pride, could they be 
accumulated and counted. 
If to the increased safety, which brings with it bolder methods 2 
WARREN, 
of operating, we could add increased accuracy of diagnosis, the 
percentage of cures ought to be advanced to a still higher point 
than it has already by the present improved methods. Until 
the future reveals to us that long-hoped-for panacea for cancer, 
it will be along these lines that surgeons will still seek to make 
progress. 
It is with the hope of stimulating further research in this 
direction that my observations are submitted to the members of 
the Association. 
The importance of an early recognition of malignant disease 
was first strongly impressed upon me by the following ex- 
perience : 
Case I.—A lady, forty-five years of age, was brought to me by her 
physician to show an induration in the breast below the nipple, which 
had followed a blow received from a sharp object eight weeks before. 
The swelling immediately following the injury had diminished some- 
what, but had not entirely disappeared. There was no retraction of 
the nipple, no dimpling of the skin, and no enlargement of the glands 
in the axilla. The patient’s general health was good. The growth 
appeared to be of an inflammatory nature, and I accordingly advised 
her to report to me again in a few weeks. At her second visit, two 
months later, the breast was found to be entirely infiltrated with can- 
cerous disease, which had also invaded the axilla. Operative inter- 
ference seemed then to hold out little hope of success, an opinion 
which she received from other surgeons, and, in spite of a resort to 
the use of caustics, she died seven months later. 
The class of cases which run such an acute course as this are 
not usually regarded as amenable to operative treatment, but 
who can say that a prompt removal of the small indurated mass, 
together with the organ which contained it, might not have 
saved a life ? 
It is precisely in this class of doubtful cases that the surgical 
specialist is frequently consulted by the general practitioner, 
and it would be more creditable to surgery could a definite reply 
always be given. The golden opportunity is but too often lost 
while waiting for the external signs which are the expression 
of an advanced stage of the disease. EARLY DIAGNOSIS OF MALIGNANT GROWTHS. 
3 
The favorable results attending the removal of cancers by 
operative measures appear to be in direct proportion to our 
ability to include a sufficiently large area of the surrounding 
tissues. The area involved around slowly growing cancers is 
probably less than that infiltrated in the acute forms, and it is 
for this reason that greater success attends their removal. Could 
we attack the acute types in their earliest stages of develop- 
ment, it might be as easy a problem to encircle the diseased 
tissue with the knife as it is in a case of extirpation of cancer of 
the lip. 
A knowledge of the anatomical relations of this infected zone 
to the primary seat of the disease is indeed a most important 
element of success in operative treatment. 
The attempt to make a microscopical examination of morbid 
growths before their removal dates back to the earliest period of 
surgical histology. A sharp-pointed grooved director, armed 
with an ivory handle, which screwed on to a case of the same 
material, was frequently used by the last generation of surgeons 
for exploring various forms of swellings. The presence of fluid 
of any kind could thus be readily detected, and such fragments 
or juices as could be extracted from a solid tumor were placed 
upon the slide, teased with needles, and submitted to micro- 
scopic examination. More elaborate instruments were from 
time to time invented, but the imperfect development of the art 
of studying morbid growths microscopically made the method 
uncertain, and led to mistakes in diagnosis. 
The pain attending the operation, and the danger of inflam- 
mation following it, were additional reasons for abandoning the 
method as unsatisfactory and unsurgical. In the meantime, the 
technique of histology has been so perfected that accurate obser- 
vations can be made from comparatively minute fragments of 
tumors. The work of the freezing microtome or more elaborate 
section-cutter is beyond comparison with the needle-work or 
free-hand cutting of even a few years ago. Antiseptic surgery 
has reached that point that such a little operation as this can be 
performed almost with absolute certainty of absence of inflam- 4 
WARREN, 
mation. Local anaesthesia with ether spray or with cocaine can 
now make such an exploration devoid of pain. 
Some simple form of instrument that could be easily kept 
aseptic, and which would remove a minute portion of the tumor 
“ en bloc,” so that the anatomical relations of the elements 
could be preserved, was needed, and at my suggestion Dr. S. J. 
Mixter adapted an instrument, devised by him for removing 
fragments of powder from the skin, for this purpose. 
It consists in a fine canula, the size of which may vary from 
No. 6 to No. 16 Charriere’s filiere. The end of the canula is 
sharpened on its inner edge, which, when the instrument is 
gently rotated between the thumb and finger, acts like a tre- 
phine. The calibre of the instrument varies from two to five 
millimetres in diameter, a size which gives ample material for 
microscopic sections whether cut transversely or longitudinally. 
A small staff is kept within the canula to protect the cutting 
edge when not in use and to remove specimens from the canula- 
The method of making an examination js exceedingly simple, 
and can readily be carried out at the physician’s office. 
The surface of the spot to be examined having been made 
aseptic and sprayed with ether or injected with a few drops of a 
five per cent, solution of cocaine, the skin is punctured with a 
tenotome and the canula is introduced through the small open- 
ing. When the canula brings up against the tumor the instru- 
ment should not be pressed forward, but rotated gently and per- 
sistently between the thumb and one finger until it finally begins 
to enter the diseased tissue. After the canula has penetrated 
the growth from half an inch to two inches, it should be gently 
withdrawn a distance of two to three millimetres and then rotated 
in a direction slightly oblique to that which it had first taken. 
Continuing the instrument in this direction for a short distance 
the edge will cut the mass which is already contained within 
the canula so that it can be readily removed. The instrument 
is now withdrawn, its end placed upon a glass slide, and the 
stilette being introduced, pushes out a worm-like mass of tissue, 
which may be as large as five millimetres in diameter and three 
centimetres in length, or even longer. This fragment of tissue EARLY DIAGNOSIS OF MALIGNANT GROWTHS. 
5 
can be laid upon the freezing microtome and an immediate 
diagnosis be made, or it can be placed in weak alcohol, which 
gives place the following day to strong alcohol. 
A specimen, obtained in this way, represents the different 
layers of the growth from its periphery to its centre: their ana- 
tomical relations have not been disturbed; in fact, the tissue, 
when it is cut with the microtome, has scarcely been touched 
during the process of removal, and is consequently in the best 
condition for microscopic study. 
Supposing this little operation to have been performed in one’s 
office, it will be necessary, in order to keep the parts aseptic, to 
apply a secure dressing. This can best be accomplished by 
applying a minute quantity of iodoform gauze over which puri- 
fied cotton is placed and made adherent with collodion, or a 
fragment of cotton saturated with iodoform collodion, or even 
a piece of rubber adhesive plaster will be sufficient. The wound 
always heals by first intention and in no case have I observed 
any subsequent inflammation. 
The best illustration of the advantages offered by this method 
of exploration is afforded in diseases of the breast. 
A patient calls, frequently in company with her physician, 
and in great mental distress, as the question of cancer has been 
raised and left doubtful. An induration exists but no typical 
symptoms of cancer are present. The surgeon is appealed to 
for a definite opinion. To ask them to wait a few weeks is 
virtually to confess ignorance. A puncture with the canula may 
bring serum, the tumor disappearing, as has happened more 
than once to me; or, the fragment having been removed, a 
microscopical examination is sent to the physician in a few days 
and the question of diagnosis definitely settled. 
A few examples may serve to show what can be accomplished 
by this method: 
Case II.—A patient forty-two years of age had a tumor of over a 
year’s standing in the left hemisphere of the right breast. Tnere was 
great neuralgic pain and mental anxiety. No glands in the axilla, 
no retraction of the nipple. The swelling was quite hard and had 
been growing lately. Puncture with a fine canula was followed by a 6 
WARREN, 
flow of serum, with some diminution in the size of tumor. A fragment 
of the solid tissue was removed and examined under the microscope and 
found to contain acini and gland ducts supported in a dense and 
hypertrophied fibrous interstitial tissue. The diagnosis chronic mas- 
titis was made. The indurated masses were subsequently excised to 
relieve pain and the breast allowed to remain. 
Case III.—Miss C., fifty years of age, came to my office with a small 
lump on the axillary margin of left breast, of several years’ standing. 
It did not appear to be connected with the breast. The existence of 
glands in the axilla was doubtful. A little cocaine was injected sub- 
cutaneously; a small puncture was made with the knife and the 
exploring canula was introduced without pain. The puncture was 
sealed with absorbent cotton and collodion, and the patient returned 
home having suffered in no way from the examination. A diagnosis 
of cancer was sent to her physician a few days later, and the breast and 
axillary contents were subsequently removed. 
Case IV.—W. W.’K., thirty years of age, while throwing a stone 
into the water one day, injured his thigh and was carried home, where 
it was found that the bone was fractured. At the end of three months 
union had not taken place and the callus seemed to the attending 
physician unusually large. On being sent for in consultation, I 
expressed the opinion that the growth was malignant, and on my return 
home sent to his physician a canula. He readily obtained for me a 
specimen, which on examination proved to be sarcoma. The thigh 
was accordingly amputated two weeks later and the diagnosis con- 
firmed. 
Case Y.—A man about fifty years of age entered the hospital with 
a suspicious ulcer on the right side of his tongue. On questioning him 
it was found that there had been a sore there for a great many years, 
during which period it had healed once or twice for a short time. The 
present lesion had existed for six months. During the last three 
months he had been under observation and had been taking iodide of 
potash. There was no gluing down of the tongue to the floor of the 
mouth : when the tongue was shown the ulcer projected fairly oyer the 
incisors. It was suggested at a consultation, that the mixed treatment 
should be given for a few weeks. But as the edges were growing and 
the size of the ulcer was increasing and no glandular involvement had 
yet occurred, I decided to remove a portion for microscopic examina- 
tion. A few drops of cocaine made it possible to introduce the canula 
through the base of the ulcer from end to end, so that a section of the EARLY DIAGNOSIS OF MALIGNANT GROWTHS. 
7 
whole new formation could be made. This was done on the spot with 
the freezing microtome and the diagnosis of cancer determined.1 
Half the tongue was excised two days later and no glands were found 
enlarged. 
Case VI.—L. C., thirty-five years of age, entered the hospital with 
a swelling in the right iliac fossa, following a swelling of the right 
testicle which had since subsided. There was some pain in the affected 
part and the patient was transferred to the surgical wards, as it was 
thought possible that an abscess or necrosis of the bone was to be dealt 
with. The exploring canula was introduced and the diagnosis of sar- 
coma having been established, a cutting operation was avoided. 
This little instrument has now been used in over one hundred 
cases by myself, Dr. Mixter and others, and with little or no 
discomfort to the patient, and satisfactory results. It has been 
even used in abdominal tumors; in one case in which the diag- 
nosis was doubtful, the growth was found to be a fibroid and 
not as had been feared a sarcoma, and laparotomy was success- 
fully performed by Dr. Homans. I have used it in one or two 
growths involving the abdominal parietes and peritoneum, but 
not in deep-seated organs. 
In two cases of tumor of the kidney I employed successfully 
the following method: A large-sized aspirator needle having 
been introduced with due antiseptic precautions into the tumor, 
a certain amount of bloody fluid was drawn into the vacuum 
chamber. On withdrawing the needle it was separated from the 
tubing and the contents of the needle itself were pushed out by 
a fine stilette on to a cover-glass. In both cases a small amount 
of solid tissue was found which had caught in the interior of the 
needle. The liquids which had passed into the bottle were dis- 
carded. In the first case a diagnosis of carcinoma of the kidney 
was made and in the second sarcoma of the kidney, both of 
which diagnoses proved to be correct at the operations sub- 
sequently performed. 
For the purpose of determining how large a fragment of tissue 
1 At the Massachusetts General Hospital a salaried histologist is present on operating 
days and specimens are examined before, during, or after an operation, and stained sections 
prepared for the purpose either of diagnosis or demonstration. 8 
WARREN, 
could be removed, I have had the size of the canula gradually 
increased until Charriere’s No. 16 has been reached. 
No ill effects are found in using this larger size, the wound 
made being apparently as trivial as a puncture with an aspirating 
needle. The sections made from the fragments removed are 
ample enough in their dimensions for the most complete micro- 
scopical demonstration. Morbid growths of the skin constitute 
a large class of the neoplasmata, particularly those seen in 
“office practice,” and in many cases the diagnosis is obscure. 
The canula can be used without pain or discomfort in many of 
these cases. I have found it easy to demonstrate the epithelial 
nature of doubtful growths upon the face by this method, which 
can be so used as to cause no additional disfigurement in the 
lesion. 
Fig. i. 
The advantages of the instrument, of which a drawing of the 
large size is given, are its simplicity, which enables one to keep 
it in an aseptic state of cleanliness, and the ease with which it is 
handled. It requires a little practice first to introduce it gently 
into the new growth by a rotary rather than a pushing motion, 
so as not to bruise or injure the anatomical structure of the plug 
removed; secondly, to withdraw the canula a short distance and 
then to advance it in a slightly different direction in order to cut 
off the plug which lies inside the canula. The latter is the most 
difficult part of the manoeuvre to accomplish without causing 
pain to the patient. 
Doubtless, further use will suggest improvements in the 
instrument, or a far better instrument. My object in bringing 
the result of my observations before the Association is to show 
that modern improvements have made an old and discarded EARLY DIAGNOSIS OF MALIGNANT GROWTHS. 
9 
method not only practicable but a valuable addition to our 
means of surgical diagnosis in difficult cases. 
Fig. 2. 
Exact size of sections taken longitudinally from a specimen removed by the canula 
and mounted on a slide. 
Fig. 3. 
A specimen. Cross-sections from such. 
Fig. 4. 
A drawing taken from a microscopic field in the section of Fig. 2 which was taken 
from a cancerous breast.