George N. Papanicolaou

Exfoliative cytology of the human mammary gland and its value in the diagnosis of cancer and other diseases of the breast

PONTANEOUS nipple discharge, unrelated to S pregnancy or lactation, is usually regarded as a sign of mammary disease or endocrine dysfunction. The discharge may be serous, serosanguineous, or sanguineous; however, its macroscopic appearance does not constitute a reliable indicator of its underlying cause. In view of the fact that spontaneous secretion may occur in the absence of any palpable localized change in the mammary tissue that would pinpoint an area for biopsy or needle aspiration, a microscopic examination of the secretion might be reasonably expected to serve as a valuable aid in diagnosis. Microscopic examination of smeaxx of spontaneous nipple discharge was begun in this laboratory by the senior author in 1947. Preliminary observations were sufficiently encouraging to warrant further exploration of this application of the smear technique, particu

The diagnosis of early human pregnancy by the vaginal smear method

The study of a large number of vaginal smears from different mammals, especially from guinea pigs, during the last several years has led me to realize that pregnancy as well as different pathological conditions of the ovaries and the genital tract might be diagnosed more or less accurately by such smears. The entire composition of the vaginal smear changes rather typically under different conditions. Pregnancy, cystic or other degenerative changes of the ovaries, inflammatory processes, growths, etc., affect the entire genital tract, including the vagina, in a way which produces definite and typical changes in the consistency and make-up of the vaginal smear. The presence or absence of different types of desquamated cells, as well as the varying form and number of leucocytes, lymphocytes and erythrocytes and bacteria, offer a variety of criteria upon which a diagnosis of certain conditions may be based. Since diagnostic reactions are of more interest and importance in man than in other mammals, I have tried for some time to secure proper human material on which to further these studies. It had been difficult, however, to obtain good reliable human vaginal smears until recently. This has now been rendered possible by a coöperative arrangement between the Department of Anatomy of Cornell Medical College and the Womans Hospital of New York aided by the Maternal Health Committee. This arrangement has afforded the opportunity to study a large number of human vaginal smears from normal cases as well1 as from cases of pregnancy, and from several pathological lconditions. The normal human smears differ considerably in. cellular composition from those of lower mammals, yet they nevertheless show typical and characteristic changes which may serve to indicate a number of distinct stages.

Neutralization of Ovarian Follicular Hormone in Women by Simultaneous Administration of Male Sex Hormone.

Conclusion Studies of vaginal smears and biopsies indicate that the male hormone (testosterone propionate) is able to neutralize, in women, the effects of estradiol on the cornification of the vaginal epithelium.

The exfoliative cytology of the mammary gland during pregnancy and lactation.

The present study was a natural outgrowth of a larger program of investigation of the exfoliative cytology of the normal and diseased human mammary gland (Papanicolaou, 1954). The purpose was: Lrst, to describe the exfoliated cell types normal to the mammary secretion during pregnancy and lactation; and, second, to evaluate the possibility of utilizing the spontaneous secretion during these periods in screening for unsuspected carcinomas of the breast. The study of smears of colostrum during pregnancy and after parturition is not new. A s early as 1838, Donn6 made microscopic examinations of unfixed human colostrum and noted the presence of “granular bodies.” To these granular bodies, Henle (1841) later gave the name colostrum bodies, a term that has been retained in most of the literature on this subject. The majority of the subsequent papers have dealt with the origin and nature of the so-called colostrum bodies. Their origin has been described as mesenchymal (Bizzozero and Vassale, 188T), leucocytic (Czerny, l890), histiocytic (Gruber, 1924), and epithelial (Gregoire, 1930 and Engel, 1953). Wallich and Levaditi (1905) and VarrierJones (1924) presumed that some colostrum bodies were derived from the epithelium and others from the mesenchyme. Still other authors (e.g., Forsell, 1939) have felt that the colostrum bodies of the early investigators were not cells but merely agglomerations of fat globules. ‘4 smaller number of papers have described the different cellular elements present during various stages of pregnancy and lactation. LouriC, in 1900, reported observations on the cytology of postpartum breast-secretion smears taken before and after the initiation of nursing. Five years later, Wallich and 1,evaditi described the cytologic differences in human milk during full lactation, slackening, and weaning of the infant. The most extensive material to date is that of Xhenseval (1949), who studied smears of mammary secretion from women in various stages of pregnancy from the first month to term, after parturition, following weaning, after abortinn, and from seven women who were nut pregnant. The above reports deal Lhiefly with the relative number and slruc turd variations of the single cells to be seen in the smears. With the exception of the work done by Xhenseval, there has been little attempt to compare the exfoliative cytology of the mammary gland during pregnancy and lactation with that of the nonpregnant state. As for the diagnostic use of breastsecretion smears in these stages, Xhenseval stressed their value in determining fetal deaths in u/ero and in detecting concealed abortions orer a period of six weeks. No mention is made of their use in the detection of diseases ol thc breast.

A Further Analysis of the Hereditary Transmission of Degeneracy and Deformities by the Descendants of Alcoholized Mammals. II

Table II gives the relationship between the size of the litters and the mortality of the descendants from different combinations. It brings out in a way the variable internal and external factors to be considered in interpreting the conditions of the members of the numerous litters of animals. The external factor considered in the table is one of nutrition or environment, depending upon the number of young developed in the uterus at any one time. The table indicates the influence of an internal factor, the germ plasms concerned in mating related or non-related animals. Four combinations are considered: pairs of normal non-relatives, pairs of alcoholic nonrelatives, pairs of normal relatives, and pairs of alcoholic relatives. The first vertical column shows that in mating together normal non-related guinea pigs of the stocks used in these experiments the average litter contains 1.96 individuals. Fifty-one and eleven hundredths per cent. of the young were found in litters of two, and 20 per cent. of the animals occurred in litters of three. Fifteen and fifty-five hundredths per cent. of the animals were born in litters of only one young, and 13.33 per cent. in litters of four individuals. The next space below in the table shows the number and percentage of individuals living over three months 144

Cytologic evaluation of breast secretions.

Cancer of the female breast continues to be one of the leading causes of mortality in the United States. Public education, largely sponsored by the American Cancer Society, has had some success in alerting women to this disease by encouraging the practice of breast self-examination. During the past 10 years, much progress has been made in the treatment of carcinoma of the breast, but little, if any, has been made in diagnostic methods designed to detect mammary cancer in its early stages. Inspection and palpation still remain the chief methods of diagnosis. Transillumination is used mainly to distinguish cysts from other masses. Aspiration biopsy has also been utilized to determine the nature of an isolated mass in the breast or to confirm a clinical impression of cancer. The study of soft tissue X rays of the breast has been explored but appears to have a limited application. There is need for additional diagnostic weapons that can be used by the practicing physician. I t is hoped that the accuracy of diagnosis of early mammary carcinoma will be increased with the aid of cytologic examination of breast secretion. References in the literature on the study of breast secretion date back to the middle of the nineteenth century.’ Since then, there have been many reports which, however, deal chiefly with the examination of colostrum. It is in more recent years that attention has been drawn to the diagnostic significance of breast secretion. Adair, in 1930,2 pointed to the value of microscopic examination of breast secretion for determination of thc presence of blood. Jackson and Severancea published a report in 1946 on the cytologic study of nipple secretions. Jackson continued this work and, with Todd and G o r s ~ c h , ~ reported on the value of cytologic study of breast secretion for the detection of silent papilloma. Observations on the normal and malignant exfoliated cells found in breast secretion have been reported by Saphirs6 , and by Papanicolaou.* This present report is based on the results of the examination of over 1600 women patients from New York Hospital, Memorial Center, and private physicians. Spontaneous nipple discharge was present in some of these patients. In the remaining patients, an attempt was made to obtain nipple secretion by careful palpation, massage, or by use of a hand breast pump. These maneuvers were performed gently to prevent trauma to the breast. Approximately 900, or over 50 per cent of these 1600 patients, were found to be secretion-positive. The term “secretion-positive” is used to designate those

Action of Gonadotropic Hormones in Amenorrhea as Evaluated by Vaginal Smears.

Summary The desirability of a reclassification of the amenorrheas based, in part, on the vaginal smear picture has been suggested. Definite smear changes indicative of ovarian stimulation and resembling the normal cycle have been induced in amenorrhea by means of gonadotropic hormones. The vaginal smear should afford a simple and sensitive method for evaluating the effects of such hormones in the human subject.

Inhibitory Effects of Male Sex Hormone on Human Menstruation and Their Evaluation by Vaginal Smears.

Conclusion A study is presented in which the administration of testosterone propionate interrupted regular menstrual cycles in a young woman. Menstruation was resumed after cessation of treatment with this hormone. Vaginal smears showed that during the period of induced amenorrhea there was a replacement of the normal smear picture by one of the typical atrophic menopausal type, indicating a temporary suppression of ovarian follicular activity. This smear type was preceded and followed by characteristic intermediate stages and persisted throughout the course of treatment, and for a short time afterward. It was then followed by gradual resumption of follicular activity and a normal smear picture. The next menses occurred 28 days after the last dose of Oreton and about 12 to 13 days after the establishment of follicular activity. This study furnishes a method for controlling the use of male sex hormone in women, and for inducing a temporary cessation of their menstrual cycle.

Diagnosis of pregnancy by cytologic criteria in catheterized urine.

Summary Pregnancy causes distinct morphologic changes in the epithelium of the urinary tract which are reflected in the cytology of the “urine sediment smear.” There is an appearance of certain characteristic cell forms such as cells of the “navicular” type corresponding to those described in the vaginal smear of pregnancy. The urine sediment smear provides, thus, a simple, rapid and dependable method for diagnosing pregnancy. It appears to be superior to the vaginal smear in that its cytology shows greater uniformity and is more distinctive. Its practical value as a routine diagnostic procedure and its applicability in the early diagnosis of pregnancy are still to be determined.

Action of Ovarian Follicle Hormone in Ovarian Insufficiency in Women as Indicated by Vaginal Smears.

The treatment of women with ovarian insufficiency by ovarian follicular hormone (OFH) has fallen short of the expectations aroused by its successful use in animals. It is possible that the amounts of hormone necessary to produce comparable changes in man are so large 1 as to be out of the question except for occasional brief studies in humans. 2 On the other hand the failures may have been due to the lack of objective criteria for estimating dosage and evaluating effects; or the choice of ineffective modes of administration. The aim of this study was the development of an objective method for evaluating OFH action in ovarian insufficiency. The study of vaginal smears has been of great value in observing the effects of OFH in rodents and other mammals. Recent studies 3 have demonstrated a cycle in the vaginal fluid of the human comparable to that in animals. The applicability of the vaginal smear method to the study of the effects of OFH in the human is briefly described in this report. Fifteen women with ovarian insufficiency, following either bilateral ovariectomy or the menopause, were observed over periods of several weeks to a year. After a control period to establish the character of the vaginal smear and the absence of OFH in the urine, treatment was begun. Smears were taken regularly over long periods and at varying intervals after administration of the hormone. The dose of OFH was adjusted from time to time until changes occurred in the smear. Subjective symptoms, such as hot flushes, headaches, nervousness, mental depression, and libido were also noted.