TREATMENT OF SARCOMA WITH THE MIXED TOXINS OF ERYSIPELAS AND BACILLUS PRODIGIOSUS.
BY A. WORRALL PALMER, M. D., NEW YORK.
The numerous modes of treating sarcoma or any other variety of cancer, and the constant experimentation on the part of the profession with new methods, only go to show how inadequate is our ability to meet this intractable disease.
These neoplasms are not so rare, as there are ninety-nine authentically recorded cases, situated within the restricted domain of the naso-pharynx and pharynx.
For these reasons, and because I have been able to find only one case of sarcoma treated with Coley’s fluid reported in our homeopathic literature, do I take the liberty of occupying your time with the résumé of my investigations into the subject and my meager practical experience.
Although surgery is, at present, the best method to meet this condition, personally I believe that more investigation into or trials of the remedial treatment should be made, because cancer is a constitutional disease, and it so very frequently recurs after removal with the knife.
Apropos to this, C. Mansell Moullin says in the Boston Medical Journal: “There is at least as much hope after an internal remedy that causes disappearance by atrophy or fatty degeneration as from the most extensive removal by operation. On a priori grounds there may be even more.”
Among the numerous drugs or substances which have been experimented with are the interstitial injection of alcohol 40 per cent., by Haase; the injection of Pure Yeast Ferment, by De Bracher; subcutaneous use of 50 per cent. solution of the fluid extract of chelidonium majus re-enforced by same drug per orem; the cataphoric diffusion of mercury from gold electrodes used by Massey; and lastly the mixed toxins of the streptococcus erysipelas and bacillus prodigiosus.
From my research the last is the only one that has attained any success or wide reputation and not been relegated to the usual oblivion of other medical fads. The reason for this I consider to be because Dr. Coley has not only been persevering, but scientific, unbiased, and very cautious in its advocacy. At first he hoped and believed that in some form it would be beneficial in all forms of cancer; but he now only recommends it in sarcoma, and claims marked results only in the spindle-celled variety of this.
As in many other cases, the discovery of the influence of erysipelas on sarcomatous growths was by investigation founded upon accidental occurrences, to wit: Busch reported a case of multiple sarcoma of the face cured by an attack of facial erysipelas; Durante, a sarcoma of the neck; Biedert, an enormous round-celled sarcoma, including the mouth, nose, and pharynx; Bruns, a melanotic sarcoma of the breast; Gerster and Bull, each a recurrent sarcoma of the neck; all cured or disappeared with no return, after an erysipelatous attack. This happy result does not always follow erysipelas, as cases of sarcoma relieved by erysipelas, and later recurring or progressing after the attack is over, are reported by Busch, Nelaton, Deleus, Richochon, Winslow, Powes, and Dowd.
On account of these accidental cures a few observers produced erysipelas artificially by infusion with the living culture, with success in many cases.
Then almost simultaneously Lassar of Berlin, Spronck of Utrecht, and Coley of New York, believing that the curative action of erysipelas lay in the toxin of the living culture, experimented and found that they could produce equally good results with toxin, thereby avoiding both the danger and discomfort of the patient passing through an attack of erysipelas.
It has been shown by different observers that the combination of certain bacilli with disease toxins makes such toxins more potent, and Rogers of Paris demonstrated that the combination of the bacillus prodigiosus with the streptococcus of erysipelas greatly augmented the virulence of the streptococcus on rabbits. Thereupon Dr. Coley used the combination on the human subject in sarcoma with far better results than before.
Regarding this, Dr. Coley says he cannot say exactly what part the bacillus prodigiosus plays in the cure of sarcoma, but remarks that the only cases cured were treated by the combination.
This preparation, the combined toxins, had been given the name of Coley’s fluid, and that used during the last seven years has been made by Dr. B. H. Buxton of Loomis Laboratory.
Until about five years ago the toxins were made from cultures from a fatal case of erysipelas, but since that, sufficient strength has been obtained by passing the cultures through about fifty rabbits. The method of the preparation is virtually this: the mixed unfiltered toxins of the streptococcus of erysipelas and the bacillus prodigiosus are made from cultures grown together in the same bouillon and sterilized by heating to 58 degrees C. and then diluted in a sterilized menstruum.
In a recent conversation with Dr. Buxton he said that at present he made a double sterilization and then added some drugs such as thymol to preserve the preparation.
Dr. Coley, in his exhaustive article in the Jour. Am. Med. Assoc., August 20 and 27, 1898, affixed a table of fifty-seven cases of cancerous tumors treated with either his fluid or other preparation of erysipelatous poison with cure, or at least disappearance of the then present manifestation of the disease and lengthening of the usual period of a recurrence of the condition.
The following is a list of cases of sarcoma of the nose and throat treated by cultures of erysipelas, or Coley’s fluid, the physicians in charge, and the time the patient is living after treatment at the time of the report in Dr. Coley’s paper, in 1898:
(a) A spindle-celled sarcoma of the neck and tonsils, inoculated culture—patient living six years after.
(b) A spindle-celled sarcoma of the parotid; it had been extirpated twice previous to treatment—patient living one year after.
(c) A sarcoma (mixed celled) of the parotid—patient living three years after. The foregoing under Dr. Coley’s care.
(d) A spindle-celled sarcoma of the palate and pharynx extending to the vocal cords—Dr. W. B. Johnson—living four and three-quarter years.
(e) A round-celled sarcoma of antrum, pharynx, and neck—Dr. L. L. McArthur—child aged five years, weight gained from 37 to 69 pounds—later, fatal recurrence.
(f) A round-celled sarcoma of parotid, size of the fist—Czerny of Heidelberg—living over a year.
(g) A spindle-celled sarcoma of the parotid—Horace Packard—living two and three-quarter years.
(h) A round-celled sarcoma of the neck—H. Montague—slight return in six months.
(i) A recurrent sarcoma of the neck and tonsil—J. O. Roe—six months after treatment died of erysipelas.
The mode of administration is cumulative. The injection is of course to be made under the most thorough antiseptic principles attainable. It is by far preferable to make the injection into the growth itself, although, if this is impossible, it may be introduced into the nearest accessible point, but in the latter case the dosage needs to be doubled.
As a rule one-half drop is the initial dose, and this is increased one-half drop each succeeding day until toleration is reached. This is evidenced by the natural reactionary fever rising to 102° or 103° F. In such case the following dose should be the same as the preceding, and if it should again go so high reduce the next dose one-half drop. The dose is increased in this manner until the maximum is attained. When applied to the neoplasm itself 8 drops is the full dose, or if elsewhere, double that amount, 16 drops.
This last amount is to be continued daily until the tumor has disappeared.
The toxin may commence to reduce the tumor in a week, but its administration should not be abandoned in less than three weeks’ trial. The time necessary to effect a cure is very variable; occasionally the neoplasm will almost disappear in two weeks, while on the other hand it may take several months.
The reactionary symptoms are a chill, followed by fever, generally lasting about three hours, although occasionally it may continue twelve hours; acute transitory swelling of tissues in the immediate vicinity of injection; usually myalgic pains commencing at point of injection and radiating frequently over the whole body; in the more severe reactions there is nausea or even vomiting—in my own case it produced a weakening menorrhagia.
Case.—Mrs. E. C., æt. thirty-four years. A tall, thin woman of neurotic temperament.
Family History.—Father had chronic bronchitis, but died of kidney disease. Mother was an invalid for seven years with rheumatism of hip and knee until death, which was caused by apoplexy; a sister died of gastric disease. The patient married eleven years; has two children living; boy at nine months died of entero-colitis; boy three and one-half years died of fall from window; two miscarriages. At ten years æt. the patient had diphtheria; at twenty-six, pleurisy; at thirty-one years, rheumatism of left shoulder and post-cervical region. It is impossible to obtain any indication of hereditary predisposition.
Subjective Symptoms.—Complains of post-nasal dropping of mucus, constant short hacking cough, malodorous breath, pain in region of spleen; aggravated when lying down and throbbing in character when walking rapidly. After discovering the swelling in the throat and speaking of it she admitted there had been a sensation of a lump in the throat for about a year, but so slight she considered it of little consequence.
Objective Symptoms.—Nares: Rhinitis sicca, covered with dry crusts, but turbinated bodies hypertrophied.
Naso-pharynx and pharynx: Mucosa slightly hyperæmic, follicles inflamed and enlarged. On the left side of these cavities is a sessile swelling, the general surface of which is much inflamed, and half of the surface is covered with varicose veins about one-eighth of an inch in diameter; it extends more than half the width of the pharynx and vertically from the vault above to the lateral sinuses below; is neither painful nor hyperæsthetic; it has a boggy feel, but not as soft as an abscess. The tumor springs from the posterior wall of the pharynx, not connected with the tonsil, as the left posterior pillar lies in front of the neoplasm and can be lifted free from it. Neither of the tonsils is inflamed nor hypertrophied; a few cervical lymphatics on the left side are slightly indurated, but slightly sensitive—if at all.
The swelling had probably existed longer than an abscess would be in forming, and there was neither pain nor fluctuation. Still an exploratory incision was made, but with the expected negative results.
Although the tumor was situated over the principal chain in lymphatics of the pharynx, it was not nodular, but smooth. Therefore the neoplasm was probably not of lymphatic origin, but an implication of the muscular tissue behind the pharynx.
A specimen was submitted by Dr. Klotz, the pathologist of the hospital, and the provisional diagnosis of angio-sarcoma made—sarcoma because it seemed to spring from the muscular tissue and apparent predominance of blood-vessels, and of the angiomatous variety because of the enlarged blood vessels on the surface.
The removal of the specimen for microscopical examination caused quite a severe hemorrhage, lasting about two hours, notwithstanding the employment of the usual hemostatics.
The microscopist pronounced it a small round-celled sarcoma.
I showed the case to the Academy of Pathological Science, where two general surgeons who examined the case advised against extirpation of the tumor, because of its close proximity to the important blood vessels and nerves of the neck, an opinion I entirely coincided with, because of seeing two similar cases before. This agreement decided me in determining to try the mixed toxins as the treatment promising the best results for the patient.
April 4. Commenced injections with one-quarter of a drop. I diminished the initial dose one-half because Dr. Coley personally advised it, as he thought the possible reactionary local swelling might seriously interfere with respiration.
April 14. The dose was increased one-quarter drop each day to date—when she took only two drops, because it was deemed advisable to omit treatment two days during menstruation on account of great weakness of patient.
April 20. Increased dose half drop per diem—on 16th and 19th treatment omitted on account of debility—dose 4 drops, which dose was continued till April 23, when on account of the temperature twice having risen to 103° F. and menorrhagia having supervened only ten days after previous regular menstruation, I thought it prudent to reduce dosage to 3½ drops, which was continued until April 26. Examination of pharynx to-day for first time showed a decided diminution in the congested appearance and size of the tumor. Formerly the tumor pushed the posterior pillar forward, so that, if the pillar could not have been lifted away from swelling by the ring probe, it would have seemed to be part of it; while to-day a small space could be distinguished between the tumor and the pillar. Dosage 4 drops.
In résumé, I would call attention to the apparent susceptibility of the patient to the toxin. Because, although she never received over half the maximum dose, the following reactionary symptoms developed: Of the seventeen days on which full records were kept, on thirteen she had chills after every dose; there were muscular pains throughout the left side, occasionally extending to the right—one-third of the time the patient was nauseated, and three times vomited—the average temperature was 100.8° F.; twice it did not rise at all after injections of ½ or 2½ drops. ’Tis well to bear in mind that chills very seldom occur after the third injection.
Finally, I wish to thank Dr. Clausen, resident physician, who carried out most of the treatment while the patient was at the Ophthalmic Hospital; also Dr. Bernard Clausen, who continued it after she returned home.
REPORT ON “HENPUYE” IN THE GOLD COAST COLONY.[[3]]
BY ALBERT J. CHALMERS, M. D., VICT., F. R. C. S. ENG.
Henpuye, or dog nose, is a disease frequently met with in the Gold Coast Colony and in certain portions of its Hinterland. The hideous deformity of the face which it causes is very striking to anyone who has lived in this part of West Africa. It is also known on the French Ivory Coast under the name of “goundu” or “anakhre,” but “henpuye” is the native name (Appolonian) for the disease on the Gold Coast. The peculiar nature of the disease and the fact that, as far as I could find, very little was known as to its nature led me to make the inquiries which are now embodied in this report. I regret very much that I am unable to refer to original papers on the subject or to be certain that I have the full literature, but my excuse is that libraries do not exist in West Africa. The only references which I have met with are those mentioned in Dr. Patrick Manson’s work on “Tropical Diseases” (p. 594), and they are those of (1) Professor Alexander Macalister (Royal Irish Academy, 1882), (2) Surgeon J. J. Lamprey, A. M. S. (Brit. Med. Jour., vol. ii., 1887), (3) Dr. Henry Strachan (Brit. Med. Jour., vol. i., 1894), and (4) Dr. Maclaud (Archives de Médecine Navale, 1895). It is by the kind permission of the Governor of this colony, Sir Frederick Hodgson, K. C. M. G., that I am allowed to publish this report. I am much indebted to Captain Armitage for his kindness in giving me information with regard to the different places in which he has noticed this disease in his travels, for drawing my attention to notes of the late Mr. Ferguson on the presence of the disease in Akim and Kwahu, and for making a painting of an advanced case of the disease; also to Dr. Henderson, the chief medical officer of the colony for many kind suggestions: and, lastly, to Mr. Crowther, draughtsman in the Public Works Department, for supplying me with a map of the colony and its Hinterland. The description of the disease will be divided into the following headings: (1) the General Description of the Disease; (2) the Description of Cases of the Disease; (3) the Treatment; (4) the Morbid Anatomy; (5) the Ætiology; and (6) the Geographical Distribution.