Chapter X
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TABLE III.--DIAGNOSIS BETWEEN EPITHELIOMA AND TUBERCULOSIS (LUPUS).
_Epithelioma._ _Tuberculosis (Lupus)._
Preceded usually by continued Irritation plays no figure. Preceded irritation or warty growths. usually by nodules. Diathesis plays no known part. Diathesis evident. Coincident evidences of tuberculous disease elsewhere. Rarely multiple. Often multiple. Area of thickening ahead of Extension of ulceration not preceded ulceration. by thickening. Ulceration advancing from a Various foci, which may coalesce. central focus. Border usually raised and Border abrupt, eaten, irregular, everted, regular in outline. thickened, firm, often inverted, irregular in outline. Often assumes fungoid type. Never fungoid. Base may be deeply excavated. Base nearly level with surface. Usually painful. Seldom painful. Bleeds easily. Seldom bleeds. Never tends to cicatrize. As marginal ulceration proceeds there is often cicatrization at centre. Most rare in the young. Common in the young. Discharge is very offensive. Discharge rarely offensive. Lymphatic involvement nearly Rarely. always.
GENERAL CONSIDERATIONS CONCERNING CANCER.
Cancer is one of the most fatal of diseases, yet has no _symptomatology of its own_. It produces no _symptoms_ which may not be produced by other affections, and this lack of pathognomonic features constitutes one of the great difficulties in diagnosis. It may disturb every function of the part involved. Experimenters have sought in vain for a distinctive feature by which the disease can be recognized; neither in the blood nor in the various organic tissues have such changes been found that can be explained only on the hypothesis of cancer. The pain which it is supposed to cause is often lacking, and is extremely variable and uncertain. The cachexia of its terminal stages is not characteristic, no matter how pronounced, and may be explained by a variety of conditions, all of which may accompany the disease. The search for the suspected parasites cannot be made with such certainty as to lead to any definite conclusions. It is known by a complex of clinical conditions or by microscopic sections of tissues already removed.
When the disease is superficial it is easily recognized, but when deep-seated, recognition comes later.[15]
[15] Since the discovery of Spirochæta pallida in syphilis, Mulzer and Loewenthal have found spiral organisms on the surface of ulcerating tumors. Borrel also found spirochætæ in conjunction with helminthia in two enclosed mouse tumors, and also in a large tumor sent from Ehrlich’s laboratory. None of these authors attributed any significance to the presence of these organisms, but recently, through the publication of Gaylord, in the _Journal of Infectious Diseases_, who has found a characteristic small spiral organism in nine out of ten primary mouse tumors, and in all of the transplanted mouse tumors of three distinct strains in the New York State Cancer Laboratory, the subject has attracted new interest.
[Illustration: FIG. 95
Rat with primary cystosarcoma of thyroid; cage infection in previously healthy animal kept in cage formerly occupied by rat with same condition. (Gaylord and Clowes, Jour. Amer. Med. Assoc., January 5, 1907.)]
[Illustration: FIG. 96
Rat with tumor produced by transplantation from that represented in Fig. 95. (Gaylord and Clowes, loc. cit.)]
Gaylord’s organism is best demonstrated by the Levaditi silver method, but can be seen by experienced observers in the living fresh state. It measures from 2.5 to 7.8 microns in length, and the individuals have from four to thirteen closely packed abrupt turns. The organism measures 0.6 micron in diameter. Thus far it has been impossible to stain it with any of the aniline stains, which characteristic appears to distinguish it from the organism described by Borrel and Loewenthal. Calkins has also found this organism in a spontaneous mouse tumor in New York. The distribution of the organism in the growing periphery of the tumors, when considered in the light of Fischer’s work with Scarlet-R, would make it appear not impossible that the organism bears an etiological relation to the tumors in which it occurs.
In the light of the well-authenticated cases of cage infection and the evidence of immunity now definitely determined, the way should be prepared for the discovery of the organism or organisms of cancer. At present this organism would appear strongly in evidence as its cause.
The microscopic picture may explain considerable in regard to the future as well as the past. For instance, in a case of sarcoma the presence of small, round cells, and especially of pigment, bespeaks a degree of malignancy which probably nothing yet known can baffle. A chemical examination of the tumor after removal may make the surgeon alert regarding the future of the case, according to the amount of glycogen contained within the mass, since the glycogen content is in direct proportion to its malignancy. For a while some reliance was placed upon the percentage of urea elimination, but this is influenced by so many factors as to have proved unreliable.
The _relations which cancer bears to other diseases_ are of considerable interest. Those between cancer and trauma have been discussed; tuberculosis perhaps is the condition which, next to pure local irritation, predisposes to cancerous invasion. The transformation of tuberculous into cancerous lesions can be best appreciated where it can be most readily inspected, _i. e._, on the skin, and it is well known that lupus lesions frequently undergo this change. This is also true of large ulcers, which may undergo a direct transformation into epithelioma, or pass through the intermediate stage of tuberculous infection. Cancer in tuberculous lymph nodes is also a matter of interest. Again, cancers and tuberculous lesions may exist side by side in the same organ, as in the lung or the brain. Distinct sarcomatous nodules have been found in infiltrated lungs and alongside of tuberculous cavities, while cancer of the face will not infrequently be found associated with tuberculosis of the cervical lymphatics. Lubarsch has claimed that 4 to 5 per cent. of tuberculous patients suffer also from cancer, and that about 20 per cent. of cancer patients suffer from tuberculosis.
The _method of death_ in cancerous patients is as free from distinctive characteristics as the course of the disease. It is usually associated with two prominent features, malnutrition and some terminal infection. At the last there is usually some toxemia, which renders the closing hours free from actual pain, while if the toxemia be profound patients may linger unconscious for several days.
GENERAL REMARKS ON THE TREATMENT OF CANCER.
Accepting the views expressed when discussing the nature of the cancerous process, the following may be assumed to be true: _Cancer begins as a local disease._ There is therefore a period in its history when _if_ it be recognized in time, _if_ it be or can be made accessible, and _if_ it be thoroughly removed, it can be frequently cured. The “ifs” in the foregoing statement afford such insuperable obstacles in so many cases that the difficulties in the way of treatment are very great. It has been said that, “The resources of surgery are rarely successful when practised upon the dying.” It happens too often that these cases are not submitted to the surgeon until long after the favorable period above indicated is past. This is explained by the difficulties of diagnosis, by the inaccessibility of many primary cancers, and by the unwillingness of patients to submit to the knife. Nevertheless the best time to treat a cancer is when its existence is first suspected, and the best way is the most radical, _i. e._, by thorough extirpation.
While such extirpation should include a wide area of apparently healthy tissue and of the entire organ which seems to be involved, for instance, in the case of the liver, this last may be impossible; and yet by removal of a considerable area of healthy liver around a cancerous gall-bladder the writer has seen complete and apparent final recovery follow. The principal direction is to be thorough.
That cancer so often returns after operative attack is largely due to the fact that the general practitioner, under whose observation most of these cases first come, is slow to recognize the malady, and timid to advise radical methods.
It has been recognized that in cancer the internal administration of arsenic has been beneficial. In order to obtain the best results from its use, it must be pushed to the physiological limit and in preparations of the most active and reliable kind.[16]
[16] The preparations of arsenic which have proved most satisfactory are the imported cacodylate of sodium, which comes in capsules ready sterilized for use, and the following solution, which is original and needs to be made up in accordance with the formula herewith furnished:
(1) Dissolve 7 grains mercuric biniodide with 10 grains potassium iodide in a little water. (2) Dissolve 48 grains arsenic bromide in a little water with the aid of gentle heat. (3) Dissolve 24 grains gold chloride in a small amount of water. (4) Mix the mercuric and the arsenic solutions and then add the gold solution, which will cause a whitish precipitate, becoming brownish in color. (5) Heat this mixture and decant the clear portions, setting it aside. (6) Add 2 drachms nitromuriatic acid to the above precipitate and heat gently until a clear red solution results. (7) Add to this the decanted portion of 5, which will cause a reddish precipitate. Heat the whole mixture up to the boiling point and until all residue is dissolved. (8) Add sufficient distilled water to make 15 fluidounces. The product should be bright, clear, and wine colored.
Of this solution 10 drops are supposed to represent ¹⁄₁₀₀ grain mercuric chloride, ¹⁄₃₀ grain gold chloride, ¹⁄₁₅ grain arsenic bromide. The commencing dose is 10 minims, which may be increased to 25 or more, taken in abundance of water.
=Treatment by Toxins of Erysipelas.=--A number of years ago Fehleisen, calling attention to the fact that cancers had seemed to improve or possibly even disappear after an attack of erysipelas, suggested deliberate infection of the surface of such a growth from a case of erysipelas. In this procedure he met with some success, but there were numerous objections to it, one being the impossibility of controlling the spread of the infection thus produced. Coley, of New York, then undertook a much more systematic study of the relation between the two diseases, and devised a method of injecting the toxins produced by the streptococci of erysipelas and of reinforcing them, if necessary, by those of the bacillus prodigiosus. The intent of this treatment is to produce reasonable reaction in the hope of mitigating the rapidity of the growth, checking its progress, or even causing its disappearance. It has been on trial now for several years, and while in a few cases of sarcoma, especially in the hands of its originator, the treatment has apparently been of service, it has proved disappointing in the majority of instances.
=Liquid Air.=--The application of liquid air to superficial malignant growths has proved successful in a number of instances, but inasmuch as this is practicable in only one or two of the largest cities of the country, it is not a measure which need be discussed here at length. The liquid seems to act as an almost painless escharotic, and its use produces sloughing, or a drying up under a scab, which after a day or two will loosen and be easily detached.
=Radium.=--This remarkable element has aroused within the past few years an amount of scientific interest and experimentation with which there is little else to compare. The enormous expense of a preparation of any great activity, and the rather bewildering contradictory statements which have been made by those who use the weaker preparations, have caused it to occupy a doubtful position in any list of reliable therapeutic agencies. It is undeniable that certain rodent ulcers, tuberculous lesions of the skin, and a few carcinomatous lesions have been much improved or apparently cured by its use. It is ordinarily used in glass or aluminum tubes or capsules, which are applied upon the surface of the growth to be treated. It has also been used sprinkled upon a plaster whose surface has been prepared with Canada balsam, and thus directly applied. Again, it has been enclosed in a capsule to which a strong silk thread has been fastened so that the former may be swallowed, retained in the stomach for a few hours, and then withdrawn. These last means of using it are of questionable value. Of still less value are the suggestions to dissolve it in water or to administer water in which a receptacle containing radium has been allowed to stand. There is much of interest and perhaps something of value in _radiotherapy_, but nothing as yet of positive value in the hands of the profession generally.
=Ultraviolet Light=, or, as it is often named after its promoter, Finsen light, has proved of value in many cases of lupus, and in some cases of superficial epithelioma. Its effects, however, can scarcely be made to penetrate into the deeper tissues, and in its use it is even necessary to make pressure upon the part treated with quartz compressors, because ordinary glass shuts out a great proportion of these rays from whatever source may produce them, and because it is necessary to create a temporary anemia of the lesions, as the fluids of the body have the same effect as does glass. For these reasons the method, which is of but limited value, can be made serviceable in but a small proportion of cases.
=X-ray Therapy.=--The Röntgen or cathode rays have played a large
## part during the last few years in the therapy of cancer. Such varying
statements have been made concerning their value as to keep them still on trial and nothing very positive can be said regarding their efficacy. It may be said, however, that the nearer the malignant growth is to the surface of the body the more promptly can their effects be produced. The superficial growths, especially of the epitheliomatous variety, often yield readily to their use; the deeper the lesion the more vague the effect, both in character and permanence. It has been the writer’s experience that they furnish the best method of relieving pain, in a large number of these growths, short of the anodyne effects produced by powerful drugs, which are in every other respect undesirable. He holds that no one can predicate with certainty what may be their effect in any given instance, but that they are worthy a trial in every inoperable, painful, or otherwise hopeless case. Occasionally improvement follows their use, while in the next, apparently a similar case, one may be doomed to great disappointment. There are as yet no indications by which the cases which are most amenable can be easily recognized. Even in cases of extensive and disseminated abdominal cancer marvellous improvement may follow, but never a cure. It is indeed questionable whether deep cancer can ever be really cured by these means. As against their undoubted and unchallenged value in some instances, certain disadvantages are met in the difficulty of selecting a proper vacuum tube, the frequency and duration of exposure, the distance, etc. _Dermatitis_, sometimes mild, sometimes severe, has too often followed the injudicious use especially of a “high” tube, and more painful, irritable, or intractable ulcers are seldom seen than some following so-called “_x_-ray burns” of the skin. Moreover this is not the worst of these cases, for efforts intended for the best have been in repeated instances turned into a travesty by the development on surfaces thus burned of epithelioma, necessitating later mutilating operation. A well-known American surgeon suffered amputation of one hand and nearly all of the other as a penalty for inattention to the destructive effects of too prolonged exposure of his hands. It has, therefore, impressed itself upon the writer that the x-rays should not be indiscriminately employed. Nevertheless in skilled hands and used with great discretion they can be made a powerful instrument for good in many cases, especially for the relief of pain. They should never be regarded as a substitute for operation if operation be feasible, but they may often be employed to advantage after operating, in serious cases, where there is reason to fear recurrence.
The efficiency of the _x_-rays is apparently enhanced by the _simultaneous administration of thyroid extract_; although the explanation for this improvement is not known, it is, however, of enough importance to be borne in mind. The extract should be given in 5-grain doses three or four times a day. All the remarks above made may pertain as well to the employment of cathode rays in non-malignant affections, _i. e._, tuberculous lesions, neuralgia, etc.
=Miscellaneous Measures.=--A large number of suggestions concerning the treatment of cancer have emanated from various sources and from men of widely different views. Beaston, of Glasgow, being impressed by the physiological relationships and sympathies between the ovaries and the mammary glands, has suggested the benefit of the _removal of the ovaries in hopeless cases of mammary cancer_, holding that the nutrition of the mamma being thus influenced there would be more or less subsidence of pathological activity. He has reported instances in which, apparently, this measure had the desired effect; nevertheless it has not found general favor.
Based upon views concerning the hyperacidity of the blood and tissues in the cancerous condition, it is believed that there is a pronounced indication for the internal use of alkalies; and the hypodermic injection of 5 minims of a 1 per cent. solution of a chemically pure soap has been recommended by Webb, on the theory that it promotes the separation of cholesterin from the living cell. He would increase the dose until 60 minims are given at one time, every other day. A 20 per cent. solution of Chian turpentine, dissolved in sterile oil, has also been recommended to be used in the same way. These are recent suggestions of unknown value.
In the general management of cancer patients, two things should be kept in mind: (1) That they are entitled to _relief from suffering_ in the least harmful way in which it may be offered, and (2) there comes a time in the history of many of these cases when all other considerations may be set aside in favor of comfort and tranquillity. Opium and other “drugs that enslave” have their disadvantages, but these cannot outweigh the benefit which they may confer in the last stages of cancer. _The terminal pains of malignant disease should he assuaged at any necessary cost of other considerations._
But while all this is going on elimination must not be neglected. Opiates are peculiarly liable to diminish secretions and peristaltic
## activity. The skin, the kidneys, and the bowels should be kept active
by measures which serve this purpose, and if it be desirable to prolong life, nutrition should be regulated and frequently administered, but it is absolutely _necessary to maintain elimination_.
The latest suggestion, viz., to treat cancer by injections of pancreatic ferments (trypsin and amylopsin), seems to the writer to be based upon erroneous notions concerning the nature and causation of the disease, and to hold out only specious hope of self-justification.
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