Paul Klemperer

Certain anatomo-pathologic aspects of hemorrhage.

The pathologist, primarily concerned with alteration of structure in disease, approaches the problem of hemorrhage with the chief question, “Where and how does blood escape from the closed channels of the circulation?” While he is aware of the significance of hemostasis for the arrest of hemorrhage, he realizes that this complex phenomenon depends primarily upon chemical and physical factors and that for its investigation physiologic rather than anatomic methods are appropriate. Yet, he will not neglect to search for morphologic evidence which might account for a disturbance in the mechanism of hemostasis. Massive, mostly exsanguinating hemorrhages, commonly of sudden onset, are generally revealed at autopsy to be the result of perforation of the heart or of rupture of arterial or venous branches. The causative role of physical injury hardly deserves further mention, except for the reference that indirect trauma (thorax compression) may cause such disruption even without the evidence of external injury. It might also be mentioned that even large perforations of the aorta need not cause death but may heal with the formation of a false aneurism. Among the morbid states responsible for the perforation of the heart, acute myomalacia due to coronary occlusion is almost the exclusive cause. Exceptional cases of gumma or abscess of the myocardium with perforation have been reported. Rupture of the aorta or the main arteries are due either to intrinsic alterations of the wall such as syphilitic mesaortitis, or medianecrosis of the aorta, or to atherosclerosis. Perforation of smaller arteries occurs in periarteritis nodosa, mycotic aneurysms due to infected emboli or to a primary structural weakness of the wall. Perforation of varicose veins such as the dilated esophageal veins, in conditions of embarrassed portal circulation, is frequently the source of fatal hemorrhage. The erosion of arteries, less frequently of veins, due to adjacent suppuration or ulceration is responsible for massive and sudden hemorrhage. Summarizing the anatomic-pathologic experiences in these catastrophic hemorrhagic episodes, it can be stated that the site and mechanism of the blood extravasation is generally obvious and easily ascertained. The situation is different in hemorrhagic conditions characterized by multiplicity and small dimensions of the initial hemorrhages, which by fusion may become extensive. While their size points to blood extravasation from small calibered vessels, the actual site and mechanism of the escape of blood is often not easily demonstrable. Rupture of small

TEAMWORK BETWEEN PATHOLOGISTS AND CYTOLOGISTS

Many years have elapsed since Papanicolaou and Traut published their classical monograph on cytology. Since then, innumerable articles have recorded the progress made in this field on all body surface areas. Morphological cytology has become an accepted routine clinical laboratory procedure as more and more persons have become interested, and have become aware of its importance and of the excellent results obtained. ,4 perusal of the literature showed that in 1946-1947, article after article was written on cytology. Today, the occasional paper discussing this subject deals with new techniques, or instruments for obtaining better results from this procedure, as abrasion brushes or smear, and cell block of secretions or body fluids. We could make this paper one of the shortest ever presented a t this academy by writing, under the title “Teamwork between Pathologists and Cytologists,” the statement “Teamwork there should be, but it is not always maintained.” One point must be made clear before we become involved in the assets of cytology. No doubt the cytologic diagnosis is an important tool, but the ultimate operative decision must still depend upon further evidence, be it a positive biopsy, or most convincing X-ray finding. 4 s far as malignant neoplasms of the uterus are concerned, we, a t The Mount Sinai Hospital, still adhere to a positive tissue biopsy before surgery or radio therapy is instigated. This procedure should be followed, even by the most enthusiastic cytologist. Progress has been made in pathology, as in all fields of medicine, and we must agree that lesions once considered benign are now considered malignant. The immortal Virchow’s diagnostic error in the case of Frederick 111, Emperor of Germany, is a prime example of our realization that a lesion may he malignant without invasion. With our present knowledge, we sometimes diagnose carcinoma a t a very early stage. True, we may ponder over the slides for days before arriving a t a final report, or other equally competent pathologists may differ with the diagnosis, but we are all aware that we are not dealing with something static. What may appear to be questionably benign today may be malignant in two or three years. Cytologists, on the other hand, do not deal with mitosis, invasion, or loss of stratification. Their diagnosis is based on changes in the individual cells. Some cytologists claim to diagnose “in sitd’ lesions as such, others go so far as to diagnose “precancerous” lesions; but the over-all general report deals with carcinoma cells present, carcinoma suspected, or negative. How, then, can a pathologist who has spent years of schooling, of specialized training, and of clinical experience associated with his specialty react toward the neophyte who invades his domain? There must be an emotional fear and