The Secrets of Specialists/Chapter 16

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If we would consider tumors as a specialty, in relation to the frequency in which they are found upon the human body, we would find this field abundantly supplied with clinical material for the Specialist. It has been conservatively estimated that there are, at least, four abnormal growths, on an average, to every adult person, which comes under the category of tumors, and it is doubtful if there is a single person in the world whose skin or body is entirely free from some blemish which does not come under the classification of tumors, while the percentage of cancerous growths invades our bodies to an appalling extent. Authenticated statistics have proven that every eleventh man and every eighth woman, over forty years of age, is afflicted with cancer.

Cancer is rated as the seventh of deadly diseases, and in England more women die from cancer than from consumption. It will, therefore, be seen what a wonderful field tumors alone offer to the office specialist who acquires a knowledge of their character and can successfully remove these growths by the modern methods of treatment.

Nearly all cystic tumors are circumscribed, smooth, movable, and of slow growth; they are painless and fluctuate upon pressure. The skin is unchanged in color, but translucent, if superficial. Aspiration will determine the presence and charaeter of fluid. Cystic tumors may appear upon the scalp, as ​in wens, or the mucous membrane, as in renula, or along the tendons, or in some natural cavity, as in ganglia. Their location has much to do in determining the diagnosis. Unless seated in some internal organ, cystic tumors rarely cause any trouble, except by weight and size; if thoroughly removed, as a rule, they will not return.

When a patient is afflicted with an abnormal development, the first thing to be determined by the physician, is the character of the growth, and to ascertain if the formation is a benign or malignant development. There are twenty-three well defined types of tumors, of which five are cysts, and the remaining eighteen are solid or semi-solid tumors. Six of the eighteen solid tumors are malignant, and classed as cancers. The use of the microscope is, of course, the only accurate way of determining the exact nature of these growths, which may be developed from a single, or different, cell tissue, in the formation of what may be known as "mixed tumors"; for instance, the lympho-sarcoma, etc., (illustrated on a following page).

The following is the classification and character of cystic tumors:

RETENTION Tumors are formed by the distention of glandular sacs or ducts, with the occlusion of the exit, as sebaceous and mucous cysts. The closure of the ducts, which is always the cause of the formation of these tumors, may be due to the pressure of inflammatory swelling, cicatrization, the inspissation, and concretion of the natural discharges at the mouth of the ducts. The closure of the orifice does not stop the secretion; rather, the irritation increases the action, and a large amount of material collects. The walls consist, at first, simply of the sac, but as the tumor increases in size, a firm, fibrous tissue may be added to it.

​EXUDATION Tumors are formed by the accumulation of the contents of pre-existing, closed cavities, as ganglion, hydrocele, ovarian cysts, etc. The cavities out of which these cysts are formed, have naturally, a small amount of fluid, but as the result of inflammatory action, a superabundance of fluid may be poured out, and a tumor is formed. The contents vary according to the natural fluid of the part, and age of the tumor, from a clear, colorless fluid to an almost solid substance.

DERMOID Tumors are formed in cavities, due to arrest of development, and contain no excretory duct; they are congenital. The contents are fine hairs, embedded in a thick, tenaceous matter. Sometimes there is found bone, cartilage, teeth and other structures.

NEW FORMATION Tumors are formed by cystic degeneration of the corpuscles of connective tissue; many of the larger cysts of the ovary, kidney and thyroid, as well as cysts in tumors, are probably formed in this way; such cysts often grow with marvelous rapidity.

​HYDATID—These tumors contain an entozoon parasite, or vesicular worm, inclosed in a distinct, separate sac. The tumor resembles an ordinary cyst, except for the presence of the little parasite, and occurs more frequently in the liver, ovary and uterus. This tumor is very uncommon in America, but when it does appear, is very short-lived as suppuration of the sac takes place and the contents escape. If this occurs to internal organs, it may produce death by the excitation of inflammation; usually, the sac ruptures, and the contents are discharged through some natural passage. When in the kidney, with the urine; the lungs, with the sputa, and the liver, with the fæces.

The ordinary retention, dermoid or extravasation cyst is best treated by excision or enucleation. If in close relation with important structures, the cyst may be incised, the contents removed and the surface of the sac thoroughly cauterized or scraped and then left to heal by granulation. Exudation cysts may be treated in various ways; the ganglion, by rupture or subcutaneous puncture, the bursa by puncture and the injection of iodine, the hydrocele by the straight incision, by aspiration or by aspiration and the injection of iodine.

LIPOMA—This tumor is composed of fat, resembling normal adipose tissue, and appears to be spontaneous in origin in most cases, but in some it is clearly traceable to injury, irritation or pressure; the growth is usually slow, many years elapsing before the tumor becomes especially noticeable; may sometimes be multiple, but do not appear simultaneously. The different tumors have no direct relationship to each other, being entirely local. They are more frequently found in the back and shoulders; soft and doughy, semi-elastic and of uniform consistency, with a lobulated surface. When under the ​skin, the integument appears dimpled. This tumor is indolent in disposition, painless, with no enlargement of the subcutaneous veins.

FIBROMA—This tumor is composed of tissue, resembling normal fibrous tissue, such as forms tendons or ligaments, and may originate in the connective tissue of any part of the body but occurs most frequently in the testicle, ovary, nerves, mammæ, uterus, and bones of the upper and lower jaw. It Image missingChondroma of finger. is not peculiar to any age, but occurs most frequently in young adults. The tumor usually grows slowly, but may, eventually, attain a larger size; it commences as a hard, firm nodule, developing slowly; is painless, hard, firm, inelastic, and of uniform consistency. Movable, unless it springs from the periosteum. Its tendency is to increase, to impair function, and, when located in some internal organs, to wear out life by its secondary effects. Does not return if thoroughly removed.

CHONDROMA—These tumors have the composition of tissue, resembling cartilage, and occur most frequently in connection with cartilage or bone. Of cartilaginous origin, the septum nasi and costal cartilage are most frequent. The femur, tibia, clavicle, humerus, bones of the forearm, phalanges and innominate bones produce most of the chondroma which originates from bone. Young persons are more frequently attacked than adults. Nearly all tumors of this class ​commence during childhood. The growth is slow, the tumor rarely attaining a large size. It is very prone to ossify, most frequently in the skeleton, as in the metacarpal or phalangeal bones. Firm, solid, destitute of elasticity. Circumscribed, usually lobulated, or marked by irregular prominence and depressions. Painless, usually of slow growth, and cause inconvenience only by weight and pressure. May undergo cystic, fibrous or osseous transformation. Its gravity depends upon the size and location. Does not return, if removed.

OSTEOMA—The composition of these tumors has a resemblance to either hard or cancellated bone; they grow, almost exclusively from the skeleton, but have been found in the interior of the brain, the eye, the lungs and other unlooked for places. Are usually found at, or about, the junction of the epiphyses with the diaphyses of long bones, when the increase in length of bone is affected, and like the chondroma, are most common in early life. Two varieties are found, the ivory and the cancellated; the former grows, usually, from the flat bones, and the latter from the ends of long bones. There may be one or more tumors; sometimes there is a veritable diathesis, bony tumors being found in every bone of the body. The growth is very slow, the tumor rarely attaining a large size; their favorite location is the thigh bone, orbit of the eye and upper jaw; they are hard, immobile, and present a rounded, nodulated surface, with a broad base, and slow, painless growth; as a rule they do not grow to a large size, unless they interfere with other organs.

LYMPHOMA—This tumor has the composition of tissue, resembling that from which lymphatic glands are formed; they originate in adenoid tissue, separated from the parent tissue by a capsule. Grow slowly and without pain.

The number of tumors which present these characteristics is very small, microscopic investigation, almost invariably, showing the presence of tubercle; they are, therefore, often difficult to distinguish by appearance from tubercular affection of the gland. The enlargement is in the neighborhood of lymphatic glands, but does not depend on tubercle or ​syphilis; they are perhaps slow in progress and maintain the original form of the gland. A pure lymphoma will cause little trouble, but the uncertainty which exists, regarding lymphatic enlargement, makes the diagnosis and prognosis doubtful.

MYXOMA is composed of imperfectly formed mucous tissue, and develops in the subcutaneous tissues; in the nose, Image missingMyeloid tumor of radius. as polypi, in the salivary glands, in the intermuscular tissue, and in the mucous cavities generally. Is found most frequently in adult life, in the shape of distinct, separate tumors. The growth is usually slow, and the vitality low; the diagnosis is often difficult, before extirpation, except when it occupies a mucous canal. The tumor is slow in developing, soft, movable, causes no discoloration of the skin, and does not affect the general health, except by the size; as a rule these growths are innocent but they often exhibit malignant traits which will bear the closest watching.

MYOMA is a tumor composed of muscular tissue, and found most frequently in the uterus, kidney and prostate. As a rule it does not develop until after the middle period of life. In some instances, as in the prostate, it seems to be merely a hypertrophy of the tissue it occupies, while in others, as in the uterus, it may take the form of a polypus, or pronounced tumor. May occur in the œsophagus, stomach, intestines, the heart, the lungs and the voluntary muscles, but its favorite seat is the prostate or uterus. Is tardy in growth, and were it not for the important organs affected, would cause little trouble.

​It is almost impossible, at times, to distinguish a myoma from a fibroma. External myomas, as a rule, are so rare and the treatment is the same; the differential diagnosis is unimportant.

ANGIOMA consists of a network of small blood vessels, held together by a minute quantity of alveolar tissue; this tumor is generally a malformation, having its origin in an abnormal dilatation of the blood vessels; ocassionally, it results from injury. Is met with as a congenital affection, being of small size at birth and then growing more or less rapidly. The ordinary locations are the skin and mucous membranes, especially about the head, face, the eyelids, cheeks and tongue. The color varies from bright scarlet of the arterial angioma to the bluish or purple hue of the veinous tumor.

In the arterial form, the convolutions of the vessels may be easily made out through the skin; the smallest pulsates regularly and often with considerable force. The pulsation cannot be controlled by pressure on a single artery. The veinous variety is of a deeper purple color, which has given it the name of "wine mark"; this birthmark will be more thoroughly discussed in another chapter, to which you are referred.

LYMPHANGIOMA—These tumors are analogous to angiomas, only that they consist of a network of lymphatic, instead of blood vessels. They are, also, held together by a minute quantity of alveolar tissue. These tumors are generally congenital, although they may appear at any period of life. They are extremely rare, however, and found in the vessels of the serotum, or lower extremities in union with elephantiasis.

NEUROMA—This tumor is composed, principally, of nerve substance, and is most frequently found on the ulnar, radial, median, tibial and perineal nerves. The exciting causes are obscure. It may, however, be traced to a bruise or wound. The progress is slow and rarely attains a large size. These tumors are very sensitive to the touch and are attended with sharp, darting pains, increased by atmospheric changes; ​they do not affect the general health unless very painful and if thoroughly removed will not return.

PAPILLOMA—These tumors are composed of papillæ, whose structure comprises a basis or central stem of connective tissue, containing usually, a vessel and a covering of epithelium; they seem to be the result of chronic inflammation, or the irritation of long continued discharges. Is sometimes congenital. Occur most frequently in young persons. Develop on surfaces which are naturally papillary and is merely a hypertrophy of the natural papillæ. It may take on different forms, according as it arises from mucous or cutaneous surfaces, or depending upon the predominence of epidermal or papillary growth; they are known by their wart-like appearance and distinguished from superficial sarcomas, and true epithelomas, by slower growth, by the lack of induration of the skin, and the absence of ulcertion. The only fear of warts is the possibility of their developing into an epitheloma; when in the bladder or larnyx, the outlook is more grave.

ADENOMA—These tumors are composed of substances resembling a secreting gland; they arise without any assignable cause, and the method of formation is very similar to that of the development of the natural gland. They grow very slowly, and rarely attain a large size. They are elastic and circumscribed and difficult to differentiate from fibroma, except by the use of a microscope. They are most frequently found in the breast and salivary glands and if thoroughly removed will not return.

While the above tumors are, as a rule, considered synonymous, they have been classified differently by different authors. I believe in the advice given by an old cancer specialist, who said: "Never refer to a malignant tumor as a cancer, but discuss the subject, before the patient, as a carcinomatous ​formation." The malignancy of these growths justifies the horror of the name "cancer." All the following cancers are generally classed as carcinomas, as their development takes place in the epithelial cells; there is one exception, however, in the sarcoma, which is composed almost entirely of cells that have their origin in those of the connective tissues, and which are embryonic in character. The following classifications of cancer may render some assistance in identifying the character of malignant growths.

SARCOMA—This tumor always has its starting point in the connective tissues. The cell element may exist separately, or in conjunction, in the same tumor. They may be either round, spindle celled, or in large, plate-like forms. The cause of these formations may be traced to local irritation, or external injury but more frequently develops spontaneously from some unknown cause, between the ages of twenty and forty; although they frequently develop in younger persons. The growth commences by one or more nodules and develops rapidly, involving the neighboring glands, which become in​corporated in the seat of disease; finally, the tumor ulcerates, and, with the advent of ulceration, the pain is greatly increased and the system becomes infected, by involving the liver, lungs or other remote organs. The consistency of the tumor may be either hard or soft, depending upon the tissue it develops within. If in the bone or periosteum it is hard, but in other parts of the body is soft and fluctuating; the growth is usually rapid and may attain a large size. Ulceration, as a rule, does not take place until late in the life of the disease. The subcutaneous veins are only slightly enlarged. The microscope shows the composition of the tumor to contain a mass of connective tissues, without alveolar arrangement, and unless thoroughly removed; this tumor will rapidly develop in the same place.

SCIRRHUS—This malignant tumor, which is also known as "stone cancer," and "atrophying cancer," is composed of undeveloped epithelial tissues; although this tumor frequently follows injury and continued irritation from low forms of inflammatory processes, as a rule, it appears spontaneously, from unknown causes. It is more frequently found in the female breast than in any other organ, although the uterus and liver are favorite seats for this growth. It is very rare for this ​tumor to make its appearance before the fortieth year of age. When this tumor is found in the breast, it will be noted as a Image missingEncephalo melanoma firm, hard, dense, nodule under the skin, firmly anchored to the integument; and, as development progresses, it connects adhesions to the surrounding parts, and becomes firmly fixed, ​hence the name "stone cancer." As the growth progresses, the pain increases. The integument becomes infiltrated and livid, and contains numerous blood vessels; if in the breast, the nipple is retracted. The tumor finally ulcerates at the end of about one year, and the discharge is very offensive. The neighboring lymphatic glands become affected early in the disease and the entire body involved in cancerous cachexias. Unless these growths are thoroughly removed at an early stage of their progress, they result in death in from two to four years.

ENCEPHALOMA—This malignant growth is often referred to as the soft cancer, rose cancer, cerebriform cancer and also fungus hematodes. They contain less fibrous tissue, but a greater quality of epithelial cells, than the scirrhus. These growths will appear at any age of life, and are almost the only form of cancer, occurring in childhood. This cancer will attack any part of the body, but is more frequently found in the breast, liver, uterus, testicle, eye, bones and lymphatic glands. These tumors are extremely vascular in structure and therefore develop rapidly, extending their destructive influence over a large surface, in a comparatively short time. They commence by a single nodule, or several nodules may develop at the same time. They are usually soft and fluctuating, easily compressed and infiltrated into the surrounding tissues which it involves. They grow rapidly and attain a large size. The superficial veins are enlarged, the surrounding lymphatics are easily involved; ulcerates readily with their undermined edges. With this event, the pain is greatly increased, which is dull and heavy in character. The constitutional symptoms are pronounced and unless every trace of the growth is removed early in the disease, it will terminate in death in eight months to two years by exhausting the strength of the patient or destroying some important organ.

EPITHELIOMA—This cancerous growth is developed from the squamous epithelium and is of more frequent occurrence than any other form of cancer. As its principal field of development is upon the skin and mucous membranes, or ​at the junctions of these tissues, it is often referred to as the "skin cancer," or the "tobacco cancer," owing to its frequency at the junctions of the mucous membranes and skin of the mouth. This tumor is also found in the cervix uteri, tongue, vagina, anus, penis, scrotum, and the entire surface of the face and scalp are favorite seats for the development of this growth. While the skin or mucous membranes, or the Image missingEpithelioma of cervex uterus. At left speculum view, at right, sectional view. junction of these tissues is the usual commencement of these cancers, their extension in growth will involve any of the structures of the body, either bone, muscle or cartilage. These tumors usually develop after the fortieth year and are due to continuous irritation, as by a pipe, or cigar, in cancers of the lip, or corrosive discharges from the uterus, etc. These ulcerations may start from a simple crack in the lip, or a mole or wart upon the face. When these cracks, incrustations or ​tubercles appear, with an indurated base, and do not yield readily to simple means of treatment, they should be viewed suspiciously, as cancerous formations, and removed at the earliest possible opportunity; otherwise ulceration may begin and extend with the progress of the disease, and lymphatic

involvement occurs; the natural development and growth of an epitheloma is not, as a rule, rapid, but a small, indolent abrasion may exist for months before the growth begins to attain a more rapid development, and with the exception of these tumors of the tongue and uterus, many years may elapse before a fatal termination.

​COLLOMA—These malignant tumors, which are also often referred to as "Gelatiform cancer," resemble, structurally, the encephaloma, but contain, independent of other tissues, a large quantity of clear colloid material. This tumor is difficult to distinguish from other forms of carcinoma previous to its removal; on dissecting, the growth will reveal the gelatinous substance it contains. These tumors are most frequently found in the stomach, omentum, rectum, ovaries and bones of the extremities, either growing as a pronounced tumor or taking on the shape of the organ in which it is situated; its general history is similar to that of the encephaloma, only it does not develop as rapidly, nor involve the lymphatic glands at an early period.

MELANOMA—These are another form of malignant growth, which resemble the encephaloma, but contains a large quantity of black pigment matter, and are therefore, often referred to as the "black cancer." This growth is most frequently found in the skin and eye, or may commence to develop underneath a pigmentary mole, and as it develops, bears every resemblance to the rete mucosum or colored skin; unless thoroughly removed, will terminate in death in a short time, as will all other cancerous formations.

The forms under which tumors may appear are manifold and give us no certain criterion as to their nature. In parenchymatous organs we either find them as sharply cireumscribed nodules or as infiltrations. In the nodular form the line between the tumor and the normal tissue is sharp, and we get the impression that the tumor grows as a solid mass, pushing before it and compressing the normal tissues. In the infiltrated form this line is not so sharp, and projections from the tumor seem to penetrate the normal tissue; by their growth the tissue between them is destroyed by pressure or by insufficient nutrition. In this way the central body of the tumor increases in size, and the infiltration continues to ad​vance. Frequently numerous small nodules will be seen in the neighborhood of a large one. These increase in size and finally meet the parent nodule, minute ones continuing to appear at the periphery. This is called growth by dissemination and is best seen in the formation of the large solitary tubercles of the brain.

Tumors which are seated on the surface of organs, as in the skin and mucous membranes, soon project above the surface, and various names have been given to characterize the form of these projections. If the projection merely took the shape of a rounded elevation, a tuberosity was spoken of.

The name tubercle was given to the smallest of these, though this name was afterward used to designate growths of a fixed histological character. When the tumors projected above the surface in such a way that the summit was broader than the base, and hung over it like a roof, it was called a fungous growth, and a polypus when the main body of the tumor was connected with the surface by a small pedicle. When the tumor was formed by a series of projections, like the papillæ of the skin, it was called papillary, and when these projections were much longer and branched it was called dendrate.

The accompanying illustration outlines the manner of the development of tumors, relative to the tissue in which they grow.

​We know but little about the growth of tumors. They have been more studied in their histology as completed structures than in reference to their development and manner of growth.

There are two principal opinions held as to the manner in which tumors grow. One is that the growth takes place from the tumor itself, and the cells of the surrounding tissue play only a passive part; and the other is, that the cells in the neighborhood of the tumor change into cells corresponding to those of the tumor. This last theory has been variously modified. Some observers assert that the cells in the normal tissue in the neighborhood of the tumor, first return to their indifferent or embryonic form, and then differentiate themselves into those of the tumor. Others hold that the change is direct without this intermediate process.

If there is any one subject which has offered a rich and inviting field for deep study for the pathologist, it has been in the investigation of the cause of tumors, and especially the development of malignant neoplasms, and yet with all our present knowledge and theories, we are still wrapped in the shroud of darkness. However, clinical experience has taught us that there are certain conditions which seem to predispose to the development of these growths, which we will briefly review.

Investigating the location in which the greatest number of cancers develop, we find them located in organs which are subjected to irritation.

In a record of 9118 deaths from tumors seventy-eight per cent. were seated in the uterus, stomach, mammary glands and intestines; of these, twenty-five per cent were seated in the uterus, which had been lacerated by childbirth. In 219 cases of the so-called tobacco cancer, occurring on the lip, 209 were in men, and ten in women. In cancer of the lip it has also been noted that men from the lower classes, who ​smoke pipes, are more susceptible to cancer than those who smoke cigars, which are less irritating to the muco-cutaneous surface.

While these statistics are decidedly in favor of the irritation theory, on the other hand, the face of a man is more subject to irritating influences than that of a woman, from a variety of reasons, among which may be considered shaving, and yet cancer of the face is more common in women than in men.

In 344 cases of cancer at the Berlin Clinic, 42 were attributed to trauma; where special investigations were made, these cases were principally tumors of the female breast.

Several years ago, Dr. Keim advanced the germ theory as the cause of cancer, and today extensive experiments are being conducted along these lines. London leads the world in facilities to study cancer; this city has two cancer hospitals and two research laboratories, with a large corps of able medical scientists.

Mice are used to a large extent for experimental purposes. Mice, like other animals, are subject to cancer; on an average, one mouse in every 3,500 develops cancer spontaneously, and a mouse with a cancer is worth five shillings in London. If bits of cancer the size of a pinhead are taken from a mouse with cancer, and implanted under the skin of one hundred healthy mice, in three weeks about five of them will have cancer; if grafts of cancer be taken from these five inoculated, and planted under the skin of a second hundred healthy mice, in about three weeks ten of these will be cancerous; and, again, if grafts be taken from these ten and planted in the third hundred normal mice, about twenty will be affected with cancer, and these experiments may continue until ninety per cent. will be affected. Cancer has not been communicated from man to mice, or vice-versa, and it has not been successfully proven that it can be transferred from one human being to another. Of course, these experiments cannot be conducted as recklessly in man as they can in mice, but they prove that the disease can be communicated in this way.

​Tumors have long been recognized as hereditary, or we might say, there often exists a family predisposition to these formations. Napoleon, his father, brothers and sisters died of cancer. In some families, as well as some races, cancer appears to occur more frequently than in others. Broca has recorded a most interesting case, pointing to a family predisposition to cancer. The mother died of cancer of the uterus, her four daughters died of cancer; two of cancer of the liver and two of the breast. The first daughter's four children died of cancer, the son with cancer of the stomach and the three daughters of mammary carcinoma. The second daughter, from the first generation, had five daughters and two sons; the sons were not affected, but the five daughters all died from carcinoma. Three were of the breast and one of the uterus and one of the liver; all the above subjects lived to be thirty-five years old before cancer developed.

These are only a few instances, from hundreds of others, to prove that there is a predisposition, in certain families, to malignant growths.

Benign tumors, as a rule, develop at an early age, but carcinoma rarely develops until after thirty-five years of age, and more often at a later period in life. This is conclusive evidence that cancer is a disease of middle life or old age; when occurring in younger persons, there is evidence of senile change in their skin and appearance.

Within the last few years there has been such rapid progress in the therapeutics of tumors that we often wonder what will be the next development in the scientific world for the removal of these unwelcome visitors. The physiologic method of treatment has entered this field with a strong force of valuable accessory measures and exercised a predominating influence in many cases, and the various forms of external growths, which were formerly looked upon as grave neoplasms, are now, apparently, regarded as simple lesions, as ​they are so rapidly and conveniently removed by modern therapeutics. In the following pages, we will briefly survey the most important methods of treatment, which are used by the Medical Profession of the present period.

The knife always has been and possibly, always will be, the first means to consider in the removal of tumors, as it can be used to the best advantage in the greatest number of cases, and, in fact, is the only means we have at present of reaching internal growths. The possibilities of surgery are so well and favorably known for removing benign growths of the internal organs, that the subject will not be discussed here, but surgery for the removal of malignant growths of the internal organs bears fruit from another harvest, and still it is the only means with which we have access to these developments.

Pozzi has reported 204 cases of hysterectomy for cancer, and states complete recovery is rare; one of his cases living ten years and another six years after the operation.

Cullen has reported 141 cases of cancer of the cervix, of which only ten were living. Massey has collected reports from 482 cases of cervical cancer, with only two living. Tubingen reports 35 per cent, recovering from cancer of the extremities, and Schmidt gives a report of 28.32 per cent cured from cancer of the breast by surgical means. We therefore, find that the knife does not offer us as much encouragement as we wish it would from master hands, even if the greatest precautions are taken to cut wide and remove every remnant of the growth. While the knife will be the dependent means of removing internal cancer, until the discovery of the much sought for "panacea," which the entire scientific world is striving to obtain, in the form of some serum. The advantages the knife offers, in removing benign superficial tumors, is the rapidity in which they may be removed, and the tendency to leave a less resultant scar. The latter is of especial advantage when these growths occur on the face or other parts of the body, where scar tissue appears to a disadvantage. The ​methods of removing these tumors are fully discussed on another page.

The medical caustic treatment for cancer, or better known as the "plaster treatment," in many localities, is perhaps, the second oldest and most universally adopted treatment for cancer in present use, and there are very few caustic remedies in the Materia Medica which have not been used for the removal of tumors and especially skin cancers. These caustic plaster treatments were ushered into the healing art under a cloud of darkness, and as a rule, their originators held their formulas a profound secret, which many of them are attempting to do today, but the "tricks" of the cancer specialists, like many other things in medicine, have ceased to exist, and are the common property of the medical profession.

The first caustic remedy to be successfully used in cancer was chloride of zinc. This remedy was the secret which monopolized all the cancer pastes for over fifty years, and it is my opinion that it stands second in value today. As near as we can trace the history of this remedy, it was used in Dr. Fell's cancer salve, nearly a century ago; the original formula was:

Zinc chloride	1	dr.
Pulv. sanguinariai radicus	1	dr.
Amgli q.s. to form a paste.
Apply on pieces of kid or washed leather.

This formula has been in constant use for over one hundred years in the above, or modified forms, and many of the older practitioners adhere to this treatment today. The writer's father, who was in general practice for fifty years, has recorded forty-eight successful cures by the use of chloride of zinc.

Later, Dr. Marsden, of the London Cancer Hospital, introduced the paste which bears his name, and after his experience in treating over six thousand cases considers arsenic superior to any other known remedy, and his experience has been con​firmed by thousands of others, until today, arsenic may be recognized as the leading escharotic, for the treatment of cancer.

Arsenious acid	2	dr.
Gum acacia	1	dr.
Water	q. s.

The technique of removing cancers with the above paste, or the chloride of zine paste, if preferred, is as follows: The extent of the tumor should be well outlined, and always remember that this does not include just the surface occupied by the growth, as the cancerous growth extends, at least, from one-quarter to one-half inch beyond the borders. To avoid a reocurrence of the growth, this should be removed enmasse, ​after bathing the surface, rubber adhesive plaster or collodion should be placed about the tumor so as to protect the healthy tissues. The outer integument may now be curretted or removed with salicylic acid, as the arsenious acid does not act well upon the unbroken integument and only detains the operation. Previous to the curretting, it is well to thoroughly anæsthetize the surface, with a two to four per cent. quinine and urea hydrochloride solution; the arsenic paste is now spread over the tumor, and a piece of rubber adhesive plaster should be cut large enough to cover the entire surface occupied by the paste, and project over the borders, which protect the healthy tissues to which it is attached. The application is allowed to remain in situ, from eighteen to thirty-six hours or longer, until you are satisfied that the growth has been entirely destroyed; during the application of the plaster, the patient will suffer more or less pain; this can be relieved by hypodermic injections of morphine, but in ordinary cases the local anæsthetic administered for the curretting will obtund the tissues sufficiently to prevent any marked degree of pain. When the plaster is removed, the tumor will present a mass of necrosed black tissue, and the surrounding area will be swollen and inflamed. If the tumor was on the face, the eyes may be swollen shut, and the ears and lips œdematus. These conditions should be explained to the patient before commencing treatment, as they have a tendency to frighten him, if not advised beforehand. The next step is to remove the necrosed mass; this is done with a flax-seed poultice; when the slough separates and comes away, you should observe if all the cancerous tissue has been removed; if you find any remaining traces of the growth left, the paste should be applied again, to remove these remnants. If you are convinced that the cauterization has been complete, the lesion should be dressed, as any open ulcer, and allowed to heal.

This apparently simple procedure is one of the most successful methods of treatment in present use, for the removal of cutaneous carcinoma, and the limit of its application will depend upon our familiarity with its action; it may be used ​on a surface from one to four inches in diameter. Larger surfaces can be treated with two or more applications until growths of quite a size are removed.

One of the most frequent questions asked is regarding the constitutional absorption, and poisoning from the arsenic.

possess, more than any other remedy, just sufficient action to excite inflammation and destroy the diseased tissue, without doing any permanent damage to the healthy structure or organism. Caution should be exercised, however, when the plaster is applied to the lips and near the eye, in order that it will not be swallowed or injure the delicate structures of the eye.

The resulting scar from this treatment is very slight, and when very small surfaces are treated they are hardly noticeable.

​

Solidified carbon dioxide offers one of the most practical and painless methods of treatment in present use, for the removal of cutaneous neoplasms, either of a benign or malignant type, and has the following advantages over any other method of treatment: In selected cases the operator always has the action of this chemical under his minute control and can regulate the extent of its action by its brief or prolonged pressure to a given surface. It is the most rapid means in our possession, of destroying these growths, as we can accomplish the same results in a few seconds which requires hours with the plaster; it is also the least painful and most convenient way to destroy these growths, and seems to possess the faculty of permitting epithelium to regenerate and thus reduces the formation of scar tissue to the minimum.

The technique for removing cutaneous neoplasms, whether it be a wart or mole, birth-mark or epitheloma, is the same. The crayon of carbon dioxide, with its contact surface brought to a point, suitable in size to comply with the surface you are treating. If it should be a small mole, the point of the carbon dioxide should be small; if the surface occupies a larger space, the point of the crayon may be as large as you desire.

The action of the carbon dioxide is to freeze the parts, and thus produce a dry form of gangrene, which nature desquamates from the healthy tissues, and leaves a clean, healthy under tissue in its place.

The application of solidified carbon dioxide is very simple; the crayon is pressed against the growth, which almost immediately, takes on the condition of freezing, and turns the cancerous mass into white ice; the crayon is moved about the growth, until the entire surface is covered. Within twenty-four hours after the freezing, the mass forms into a crust, and at the end of from ten days to three or more weeks, the crust will be forced off by nature's process. If the operation has been successful, we will find a healthy-looking, underlying tissue, which, from a cosmetic point of view, is more beautiful ​ ​than from any other means of removing these growths, and this is the treatment par excellence for the removal of all small growths, including warts, moles, birth-marks and small tumors of a malignant nature. The patient should be forewarned regarding some swelling of tissue, adjacent to the growth treated, and the pain is so slight, that patients will often not complain at all, or refer to it as a sensation of heat or cold; which, they are not always able to determine.

Dr. Bernstein recently reported fourteen cases in the Hahnemannian Monthly, one of which is illustrated here, and demonstrates the value of this indispensable process of removing these growths. The doctor states: "There have been no failures in the hundreds of cases treated; the percentage of cures still remaining one hundred," which is verified by the writer's observations.

Finsen demonstrated before the association of Danish physicians his first case of lupus, cured by the action of light. This was the beginning of a new therapy, by the energy of radiation, in the treatment of neoplasms; this system, founded by Finsen, has also involved the form of energy which is utilized in various ways, and includes, principally, the Finsen light, X-Ray, high frequency currents, radium, etc. These elements have been found, by constant observers, to have their basic effect through their ability to destroy micro-organisms which cannot resist the influence of light, as can the healthy, normal tissue. While the Finsen light is successful to a certain extent, most authorities have abandoned its use for the more powerful forms of radiation, and the Finsen light is almost limited, in the London hospitals, to the milder forms of cutaneous affections, including lupus; the other forms of radio-therapy, as a rule, are utilized for the treatment of cancers proper. While the effects of all these agents are similar, in some respects, in others there is a vast difference, which experience has taught us to differentiate and individualize, with specific indications for each. Whether cancer is due to a micro-organism or not, makes no difference so far as the ​treatment is concerned; we do know that these radio-therapeutic measures are capable of stimulating normal cell activity, in their defense against the invading cancer cells, and cause the latter to be absorbed, but just how this is accomplished no one has been able to explain. Our present knowledge in the field of radio-therapy would indicate the following conclusions: 1st. The Finsen light exerts its best influence in superficial cutaneous lesions, including lupus. 2nd. The X-Ray is more effectual in the deeper seated lesions, including epitheloma. 3rd. High frequency currents are one of the best constitutional measures to increase metabolism and nutrition, relieve pain and check the progress of disease. 4th. Radium, when its technique is more thoroughly understood, perhaps will offer us a means of reaching these growths in the deeply seated organs. Any one or all of these methods may be preceded by surgery, the freezing or plaster treatment, to reach the deeper structures, and are frequently utilized to their best advantage in destroying the remaining cancer cells after surgical measures.

The fact remains that solidified carbon dioxide is superior to any other means of treating skin cancers and therefore the technique of radio-therapy will not be discussed here. We will, however, disclose some of the possibilities and new developments regarding radium which promises such a bright future in the treatment of cancer.

It was the year 1898 that Madam Curie who was assisting her husband in his laboratory in Paris, succeeded in segregating from pitch blende, an oxide of uranium, which comes from a single mine in Bohemia. This substance which glows in the dark and gives off heat without being diminished was radium which was hailed throughout the scientific world of medical research, with a view of obtaining, if possible, its place in therapeutics. Shortly before this Finsen had announced his investigations of light, and it was immediately thought that ​radium must bear some allied influence in the treatment of disease, and continued investigation has given this substance a distinct place in therapeutics, and furthermore a place which it seems probable will be gradually extended so as to include many conditions which formerly seemed beyond its scope. The investigation of radium has been confined principally to cutaneous lesions and malignant growths where its action is specific and although allied to the X-Ray, Finsen and others light therapy, the histological changes in the cancer cells, following the application of radium rays, are peculiar to themselves, the beneficial effect is apparently due to its irritating action, producing obliterative endarteritis and fibroid changes.

Dr. Wickham has reported several hundred cases of all forms of birth-marks, from port wine stains to vascular and pulsating angiomas which have been reduced so that the skin is almost a normal color and devoid of cicatricial tissue. With these cases the treatment was prolonged to avoid any destructive influence upon the skin. Many other affections of the skin also respond to the radium treatment. Chronic eczema, lupus, acne rosacea psoriasis and other cutaneous affections have been cured after other means have failed.

Radium has been one of our greatest hopes as a means of treatment for internal tumors. Dr. Abbe was the first to employ this method by introducing tubes containing the radium salts into the center of tumors, by this means he has obtained excellent success, particularly in cases of deep-seated sarcoma. Here we have the only substance to which we have access for reaching deep-seated neoplasms, our only obstacle seems to be a means of conveying the radium to these obscure areas; this has been accomplished to a certain extent through the orifices of the body, but the results were not as satisfactory as desired, for it was difficult to place the radium rays at the point where they would derive their greatest value, and to receive the greatest benefit from this means will require the services of a surgeon, and it is hoped the near future will develop facts in this procedure which will startle the world.

​Drs. Aikins and Harrison, of Toronto, have recently reported their "observations on the therapeutic use of radium," in which they report several interesting cases, and in order that the reader may become familiar with the results obtained from this new and promising therapeutic agent I will append their report, quite in full, as I believe such reports have a tendency to point out the most valuable features of any therapeutic agent. The doctors state:

"Of rodent ulcers we have had experience with seventeen. Without exception excellent results have been, or are being, obtained. In ten a record of previous treatment with pastes, X-rays, or leucodescent light, was admitted, but no permanent curative result had followed. It is hardly necessary to go into the minute details of all these cases. After a short application of the radium placque, the small ulcers have almost invariably crusted over in ten to fourteen days, and when this crust detached itself the skin underneath was healed and smooth and of a pinkish tint, which soon faded to the normal color of the skin. These patients should be seen subsequently, as in cases where a slight thickening of the tissues remain, an application of the rays to produce a deeper penetration without an ulcerative effect, is desirable in order to insure a good result.

Where the ulceration is more extensive, longer and more frequent applications are necessary. The treatment in these cases sometimes extends over several months, as it is necessary to feel one's way very cautiously. One such case was as follows:

Miss G., 32, came under observation Aug. 28, 1910. Since birth she had had an ulcerated area in the right temporal region. It increased gradually as a child, and from the age of ten until the present she had been under treatment of various kinds. It has twice been excised, and pastes, X-rays and leucodescent light have been tried. It would improve, but that was all. Among those who have seen this case there is a difference of opinion as to the true condition. The early age at which it began would suggest a lupoid character, but ​the appearance in August suggested rather a rodent type. Dr. Louis Wickham saw the case after some radium therapy had been employed, but would not give a definite diagnosis. He expressed the opinion that it was probably of lupoid character to start with, but had taken on the character of the rodent ulcer.

When first seen there was an area of scar tissue on the right temple the shape of an equilateral triangle of one inch and a half to each side. In this area, three-quarters of an inch behind the eye, was an ulcer three-eighths of an inch in diameter punched out with thickened and slightly undermined edges. The floor was covered with pale, unhealthy-looking granulations, and there was a sero-purulent discharge. Behind this ulcer, at the lower angle of the area, was another smaller ulcer of similar appearance, and just at the angle of the eye was a small ulcer, the size of a pin's head.

A strong placque, screened, was used several times, and then the patient went home. She was seen again at the end of September. There had been a good deal of surface reaction and a crust had formed over all the ulcers. No further treatment was given at this time. At the end of October she reported again. The crust was still present, but was easily removed, and underneath the skin was formed slightly thicker than normal and redder, but with absolutely no ulceration. The parts were radiated again, using heavier screens in order to get a deep action and soften up the tissues.

It is, of course, too early to say whether this result will be permanent, but from other cases reported in the French literature we can see no reason why it should not be.

The early result here points to the condition being one of rodent ulcer rather than lupus, as experience has shown that the latter do not react so readily as the former to the action of the radium rays.

To show the result with the common rodent ulcer, the following cases may be given as examples:

Mrs. L., presented a rodent ulcer on the left side of the nose of four years' duration, which had resisted all treatment. ​Within one month after a series of radium applications the ulcer healed, and is still so at the time of writing, seven months after she was first seen.

Mr. M. showed four typical rodent ulcers on the left cheek and one on the skin of the upper lip. They had been present for two years. He was given applications of a placque of 500,000 activity, eight hours to each spot, extending over a period of two weeks. At the end of that time the radium crusts had formed.

Under date of Nov. 29th, the patient writes from New Orleans: "It affords me much pleasure to advise you that all trace of the affection has vanished, not even the smallest trace of a scar can be seen."

Mrs. R. had a small nodule on the left side of the nose. It appeared two years ago and had increased in size until it was three-eighths of an inch in diameter. It was not ulcerated. It had begun to pain a short time before. She had had no treatment of any kind. She was given a short application of a strongly active placque and on presenting herself six weeks later the nodule had quite disappeared.

EPITHELIOMA OF THE LIP.—Two cases of superficial epitheliomata of the lip have responded splendidly to treatment. Other epitheliomata have been referred on which prolonged treatment will have to be carried out, and on which we hope to report more fully later. To mention a few:

Mrs. B., epithelioma of the buccal mucous membrane, which had recurred after removal. She was seen six weeks after treatment, and there had been no reappearance; she will, however, have to be kept under observation from time to time.

FUNGATING EPITHELIOMATA.—Fungating cutaneous epitheliomata are particularly suited for radium action, and various techniques can be adopted depending on the individual case under observation. "Cross-fire" action often gives excellent results with the use of different forms of filters. A preliminary curettage and removal of the vegetations is of help in decreasing the time required for cure, but is not absolutely necessary.

​T. F. T., æt., 54, presented on Oct. 29th a fungating mass as large as a fifty-cent piece, below and behind the left ear. There had been a small ulcer for about five years, but latterly the growth had been very rapid. The growth was covered with cauliflower excrescences, and projected three-quarters of an inch above the surrounding skin. The edges were hard and everted, and the tissues about were quite hard, as though the growth extended to some depth. There were no enlarged glands to be felt. Under local anaesthetic the vegetations were removed, and the next day radium applications were made. These were repeated for four days, and then the patient returned home. He was seen again in three weeks, at which time all that was observed was a small, healthy ulcer, one-half inch in diameter. The epithelium was growing over it, and it looked as though it should be healed completely in another two weeks. The edges were quite soft, as were all the surrounding tissues. A few more applications were made to stimulate the healing, and he again returned home. On December 16th, he reported it "practically healed, with only a small crust to be detached."

SARCOMATA.—The case described below, together with one other case of cancer of the uterus, forms perhaps the most interesting study we have made.

R. J. B., æet. 53, in February, 1909, he noticed a lump at the angle of the jaw, on the right side. X-rays were used without any apparent effect as the mass kept increasing. In April, 1910, the tumor was removed and showed a small round-celled sarcoma. In June it recurred. Excision was again advised, but as a facial paresis had followed the first operation, the patient would not consider further operative procedures. He was therefore referred for radium treatment.

At first, very thorough radiation was carried out with placques, and some decrease in the size of the mass could be noticed. The cross-fire method was here used, a placque being placed on each side of the tumor.

The beginning of October the mass was two inches in ​diameter and elevated three-quarters of an inch above the level of the surrounding skin. It was quite firm and seemed attached to the underlying angle of the jaw. On Oct. 5th, an incision was made into the tumor, and a small silver tube containing one centigram of pure bromide of radium, with an activity of 2,000,000 was inserted deeply into its center. It was left in place 24 hours, and the result was most remarkable. At the end of this time there was a cavity present, into which the finger could be inserted, the growth felt much softer and was more freely movable. From the opening thus made, broken down necrotic tissue was discharged, and the size of the tumor visibly diminished. Twelve days after this first treatment the tube was inserted again, two hours daily for six days, with the placque applied externally to produce the cross-fire action.

The patient then returned home and reported in one month. On inspection no tumor mass could be seen at all. On palpation two small masses, which felt like scar tissue were present, one just in front of the ear, the other behind the angle of the jaw.

We regard this as a most gratifying result, although the patient can in no sense be regarded as cured, and will be required to be watched from time to time. He would be a foolish man indeed who would make any such claim so soon as this, but others report cases of round-celled sarcoma, removed and free from recurrence after five years, and we see no reason why the same result should not be looked for here.

CANCER OF THE UTERUS.—In many cases of cancer of the uterus radium can be of great service. Dr. Wickham has reported cases regarded as inoperable, which were so reduced as to render a later operation possible, while where there had been recurrence in the scar tissues in the vault of the vagina following operation, radium was effectual in removing it. In all cases the most striking effect was the rapidity with which the discharge and pain ceased after a very few applications.

The condition is one that offers itself very readily for treatment, on account of the facility with which the apparatus ​can be applied. Radium tubes can be introduced into the body of the uterus, or radium placques can be applied to the cervix. We have ourselves had the opportunity of verifying these beneficial results in the following cases:

A patient, æt, 53, first noticed a bloody uterine discharge in January, 1910. She did not consult a physician until June. The cervix was cauterized, but serious hemorrhage recurred, and in July she underwent an operation at the hands of a leading gynæcologist in Toronto, when the uterus was curetted, and the cervix amputated. This was all that was done, as, in the surgeon's opinion, the left ureter and bladder were involved, and hysterectomy would not be justified. A very grave prognosis was given. On August 15th, in the vault of the vagina, and where the cervix had been removed, was a raw, bleeding, granular surface, about two inches in diameter, extending into the vaginal wall. The left side was more involved than the right, and in order to remove the growth completely, an extensive dissection would have been required, and probably the removal of the left ureter.

The uterus was fixed on the left side, and examination by bi-manual method caused a good deal of pain. The body of the uterus was not enlarged.

In view of the extensive operation which would have been necessary, and the uncertainty of complete removal, radium treatment was advised.

Treatment was accordingly instituted, and from August 15th to October 7th, with two weeks' intermission a strong radium placque was placed against the cervix for twelve hours every night. The discharge ceased after the first few applications. The pain disappeared, and the bladder condition improved. On October 7th, a tube containing one centigram of pure bromide of radium in a catheter was inserted into the uterus for fifteen hours. The patient then returned home. Examinations made from time to time had shown a continuous improvement and lessening of the area of ulceration. On November 30th, she reported, and Dr. Cleland again examined her and reported as follows:

​On Nov. 30th, the raw surface was reduced to an area about half an inch in diameter, which showed no tendency to bleed as formerly. The uterus was more movable, but still somewhat fixed on the left side. The patient reported herself as suffering no pain nor discomfort of any kind, and as having gained about 15 pounds in weight. The improvement in the local condition was most marked, and an operation could now be undertaken with more certainty of success. But, owing to the improvement under the radium treatment, it seems advisable to continue it for some time yet.

EXOPHTHALMIC GOITRE.—Dr. Abbe was the first to employ radium in the treatment of this condition. This was effected by making incisions into the thyroid gland, into which radium tubes were inserted. A great decrease in the size of the gland followed, with amelioration of the nervous symptoms, and this result has continued. Dr. Wickham, of Paris, has also successfully treated cases by the placques with "cross-fire."

A case which presented itself recently has given us an opportunity to observe the action of radium in this condition.

Mrs. M., æt. 31, noticed a small lump at the root of the neck five years ago. Local applications were used, but there was no change one way or the other. One month ago it began to grow, particularly on the right side. The tumor protruded and began to cause distress in breathing, speaking and swallowing. At the same time she began to feel tired, with loss of energy and appetite. Examination showed enlargement of the isthmus and right lobes of the thyroid, the tumor being quite hard in consistency. The circumference of the neck was 15 inches. The pulse rate was slightly increased.

Applications of radium placques have been made, and already within three weeks there has been marked improvement. The tumor has decreased, so that the circumference of the neck is only 13 inches, and the pressure symptoms have quite disappeared. The improvement in this short period of treatment has been so marked that a further decrease in the size of the thyroid can confidently be expected.

​POST-OPERATIVE PROPHYLAXIS.—Dr. Wickham, in his latest papers, insists strongly on the association of radium with surgery. He claims that in many cases the radium rays will turn an inoperable case into an operable one, and further, that after operation for malignancy, when, no matter how extensive the dissection, one can never be sure of having removed all the cancerous tissues, radium should be used over the scar, and area of operation, as a prophylactic measure to destroy any stray neoplastic cells.

In three cases we have so applied the treatment, two being sarcomas and one a carcinoma. In the latter case, which affected the breast, the radical operation was performed, and some enlarged glands were present in the axilla, which on microscopical examination were shown to be simply inflammatory. Radium applications were made over the line of suture, ten days after operation. This treatment was repeated in one month. Whether the treatment has had any effect, we will probably never be able to tell, either one way or the other, as, of course, surgical treatment alone is very often effectual in these cases.

The other two cases were sarcomata. One was in a male infant, in which a round-celled sarcoma had developed at the side of the anus. It was removed by surgery, but reappeared in two weeks.

Very thorough radiation was carried out and has been repeated at intervals since, with the result that there has been no recurrence during four months, although all who saw the case regarded it as one in which recurrence would probably occur, and gave a very grave prognosis.

The other occurred in a man of 61, on the suggestion of Dr. Wickham, of Paris. He had had a spindle-celled sarcoma of the tissues on the right side of the neck, which had been removed first in May, 1908, and, owing to a recurrence, again in May, 1910. It soon recurred, however, and a very extensive dissection was done in London, England, in August, 1910. Six days after the operation he went to Paris, where radium applications were made by Dr. Wickham for a period extending ​over three weeks. As a prophylactic measure, he was advised to have this treatment repeated at intervals, and in Toronto in October, 1910, was given another thorough radiation over the field of operation and particularly at points where the scar tissue was in excess. By this method we believe any sarcoma cells can at least be held in check, if not actually destroyed.

From the experience we have had with this agent during the past few months abundant opportunity has been given to verify the results obtained by others in its therapeutic use.

Judging from results already obtained, we feel that radium therapy is only in its infancy, and that the future will disclose other pathological conditions in which it can be of great service."

There have been several attempts to inject different medicines into the substance of tumors to change the character of the growth, or to transform or liquefy indurated growths to a sloughing process, where it may be treated as a simple abscess, etc.

In certain forms of tumors this means of treatment has reached a reasonable degree of perfection, while in others it has proven deficient in the results expected; this has been particularly so regarding the aim of scientific medicine to find some serum that will kill or paralyze cancer tissue, without destroying the normal tissue in which it is embedded; it is, therefore, well for the physician to become familiar with the latest facts which have developed in these lines of treatment.

Trypsin is one of the digestive products of the pancreatic gland and plays an important part in the digestion of proteids. Dr. Beard, of Edinburgh, advanced the theory that this remedy would digest cancerous growths and convert them into a substance which can be absorbed and eliminated.

​Dr. Luther has presented a full discussion of the trypsin treatment of cancer, based upon knowledge gained by a visit to Beard and other workers in Great Britain, as well as upon some observation of his own. Beard's introduction of trypsin as a therapeutic agent in cancer is based upon embryological discoveries which he has made in the course of his studies of this subject. Instead of developing directly from an egg, the course of development of the embryo is extremely indirect. The fertilized egg undergoes karyokinetic division and subdivision to a limited number of mitoses depending upon the species. The result of this is a tissue named variously by Beard as phorozoön, trophoblast, larva, or a sexual generation. This tissue, which composes in reality, partly or wholly, the chorion, is endowed with "indefinite, unrestricted powers of growth." Digestion in these cells is an intracellular, acid, peptic one, as has been proved by Hartog.

The final division of these trophoblastic cells results in a primitive germ cell which again divides and subdivides to a various but definite number of mitoses, depending upon the species under observation. The actual number for man is not known. This division results in a number of primary germ cells, again the number depending upon the number of divisions, this being definitely fixed for every species. For instance, in the skate the primitive germ cell undergoes seven mitoses, resulting in 512 primary germ cells. From one of these primary germ cells the embryo develops. The remaining germ cells form the foundation for the succeeding generation—that is, they develop into the sexual glands of the growing embryo. Beard has observed these cells in various stages of migration into the embryo. In the earliest stages of the skate, while there are still three distinct layers, no germ cells are seen while the outlying blastoderm is crowded. As time advances they are found between the layers, and later still large numbers are seen there. The objective point of these migrating cells is the germinal nidus, and after arriving there they begin to undergo division, and finally, after a limited ​number of mitoses, develop into primitive ova if the organ is an ovary, or spermatogenic cells if a testicle.

After the embryo is well formed and the organs mapped out and functionating, the trophoblast is no longer of use and disappears. The cause of this disappearance is purely hypothetical, but Beard believes that it is due to the activity of the pancreatic secretion. Up to this time the cell division has been an intracellular, acid, peptic one, and from this time, which Beard calls "the critical period," the digestion becomes an alkaline, pancreatic one, and as a consequence these cells are digested and absorbed.

This normal course is subject to variations. During the act of migration many of the primary germ cells never reach their objective point—the germinal nidus—but, wandering between the layers of the forming somatic cells, are obstructed in various corners and crevices and forever lost. The usual fate of these vagrant germ cells is degeneration and absorption, but they may become encapsulated and remain. Should any of these encapsulated vagrant cells attempt to go through its life cycle, the result might be a monstrosity such as the Siamese twins; one embryo attached to another; or one embryo, partly or wholly developed, more or less completely embedded in another well-formed one. So we may go down through the scale to the class of tumors known as embryomas, teratomas, or dermoid cysts, which in the ovary would be the result of persistent germ cells.

In the development of a malignant tumor, either the embryonal stage is skipped by these developing vagrant cells, and in proliferating a trophoblast is formed or the cell attempts to go through with its normal cycle—the production of an ovum which in its turn develops into a trophoblast; the embryo failing, there is no "critical period" and no check put upon the "indefinite, unrestricted power of growth" with which these cells are endowed. This is an "irresponsible trophoblast," or malignant tumor.

Beard, having noticed the trophoblast gradually disappear with the development of the pancreas, decided that the ​pancreatic ferments caused this disappearance. If this were true, he reasoned that the pancreatic ferments would cause the disappearance of an irresponsible trophoblast or malignant tumor. The theory was confirmed by experimental work. The pancreatic ferment acts upon the cancer albumin and the cancer ferment in an antagonistic manner, as a result of which the tumor gradually diminishes in size and disappears by absorption, or is killed and converted into a benign fibrous mass.

Shaw-Mackenzie had introduced the use of trypsin in the treatment of cancer at about the same time, but was led to its use in an entirely different way.

The treatment consists in the hypodermic injection of a solution of trypsin daily for a period of four weeks, followed by the hypodermic injection of a solution of the diastatic ferment, amylopsin, every other day alternating with the injection of trypsin, the maximum dose of which is maintained. This for four weeks, followed by another period of four weeks or more, during which daily injections of amylopsin alone are given.

The trypsin injection which the author has used is a sterilized glycerin extract of the freshly macerated pancreatic gland, and besides trypsin it contains all the other pancreatic ferments. The amylopsin injection is, he believes, freed from the other ferments. They are both in 60 per cent. glycerin solution and consequently require dilution with two volumes of water or normal salt solution. They are put up in sterile glass ampoules, containing about 20 minims each.

The treatment should be started with a few preliminary injections of 5 or 10 minims before the full dose of one ampoule is given. After this the dose may be gradually increased. Maguire, of London, gives two ampoules, or 40 minims, as the maximum dose, but 75 minims is frequently given without bad effects. The dose of amylopsin should be graduated in the same way.

The injections may be given anywhere except into the tumor, on account of the pain and local inflammation produced. Probably the best place is the loose cellular tissue of the loin. ​It should be thrown deep into the cellular tissue, but not into muscle. The greatest care should be exercised to render the syringe and the skin at the seat of the injection sterile. Abscesses are apt to follow failure in this respect. Though the author has given over five hundred injections, not one has caused any more trouble than some soreness and induration, which lasts for a few days.

Trypsin is rendered inert by heat, consequently care must be taken to cool the syringe after boiling before the solution is drawn into the barrel.

In addition to the hypodermic injection, stress is laid upon the oral administration of some pancreatic preparation. The local application, where possible, of a liquid or powdered preparation of trypsin, or pancreatin is also recommended where the cancer can be reached. This undoubtedly is useful, for it does cause a rapid breakdown of the mass.

Some patients after receiving a number of injections show toxic symptoms which Beard attributes to the digestion and absorption of the cancer cells. These symptoms, beginning with nausea and vomiting, pain in the back and drowsiness, develop, but usually clear up promptly under injections of amylopsin, while the trypsin treatment is continued but the dose diminished. Should the trypsin be continued without amylposin in these cases, high arterial tension, albuminuria, rigors followed by rise of temperature, and coma might develop.

The trypsin treatment has been used by various observers in different parts of the world, and of the reported patients five have been pronounced cured, though in not one of them has the microscope corroborated the clinical diagnosis. It is the concensus of opinion of those who have tried the treatment that it does in most cases cause an arrest or shrinkage of the growth; improvement in the general nutrition, in which the appetite improves and the weight is maintained or increased; diminution or cessation of pain, and diminution in the discharge and fetor except in those cases in which sloughing occurs. Large doses are required, and perfection of the treat​ment will necessitate the finding of methods for obtaining pure and more concentrated solutions of the ferments so that they can be administered in reasonable quantities."

What seems to have remained undeveloped, with the trypsin and other treatments, has been successfully perfected by Dr. Calot, of Berck, in the successful treatment of certain benign tumors, especially of the cervical glands. This injection treatment is not only commendable for the most excellent results obtained, but also from the fact that it leaves little or no trace of the operation in the form of a resultant scar, in places on the body where such disfigurement is most noticeable. In referring to the treatment of enlarged cervical glands, Dr. Calot remarks:

"By what mental aberration is it that surgeons puncture cold abscesses in other parts of the body, and operate only in suppurating glands of the neck? In truth ought they not to follow exactly the opposite line of conduct, since the question of a scar is only of importance in respect to the face and neck?"

No doubt the surgeon would reply that this is the price that has to be paid for the cure of the adenitis, that the scar is the unavoidable ransom, and that sanguinary intervention is the sine qua non of perfect recovery.

Yes, but is that really the case? Some twenty years ago I used to say the same thing, with the result that I operated upon large numbers of enlarged glands.

Nowadays, I say nothing of the kind; I no longer hold it to be true; indeed, I am convinced of the contrary. For the last seventeen or eighteen years I have given up operating enlarged glands, yet I have obtained cures more numerous and more satisfactory, and in every respect, more complete than those I used to get.

At the present time thousands of enlarged glands of every degree of severity have been cured in this way without operation, by others as well as by me.

​Now this is precisely what practitioners in general are insufficiently aware of, or at any rate, they too willingly lose sight of it in practice. It is therefore, incumbent upon us to repeat as emphatically as may be, viz.:

1. In many cases enlarged cervical glands undergo spontaneous resolution, provided that they be allowed time, and are assisted in so doing.
2. The other cases of enlarged glands, those which do not undergo resolution, will break. A softened gland can nowadays be cured, without scarring, by method of punctures and injections.

Having instituted this comparison, what reason can there be not to discard sanguinary interventions for enlarged glands? A treatment that mutilates and affords no guarantee whatever against a return, indeed which very often seems to pave the way to a return.

Yes, indeed, many and many a case have we seen of this relapse in patients, in spite of the fact that they had been operated by some of the best surgeons in the two hemispheres.

These patients come to Berck for the purpose of escaping further interventions; the only result of the previous one having been to gash them, and in some instances, to leave them rather worse in health than they were before they placed themselves in the surgeon's hands.

Here is a very striking instance of the kind (Figs. 1 to 4): The young man in question was operated upon in London five years ago, for a slightly enlarged cervical gland, by one of the foremost English surgeons, so that we may take it the operation was done skillfully and completely. All the same the mischief recurred. Again he was operated upon and again it recurred. Then the patient betook himself to Switzerland where a third operation was performed, followed by a third recurrence; five months later a fourth operation with a fourth recurrence. The more they operated the more it "grew again."

More than this, after the fourth intervention, the right side, previously immune, was involved in its turn.

​ ​It was at this juncture that the patient came to us with a double tumefaction, (Figs. 1 and 3); a tumefaction so enormous and so ugly in appearance that it gave one the impression rather of a lymphadenoma than of a bacillary adenitis.

Now pray examine this same patient a year after he came to Berck, (Figs. 2 and 4). I shall explain, further on, how we treated and cured him without operation. All I ask you to bear in mind with regard to this case, (and I have plenty of others equally convincing) is this: that even the freest ablation of enlarged cervical glands, however accessible they may be, does not afford any reliable assurance of the absence of recurrence, and this is a further argument in favor of our aphorism: "Tuberculosis is not amenable to the scalpel, which rarely cures, often aggravates and surely mutilates."

Dr. Calot's injection treatment consists of two fluids, one of which is used to soften the glands, when he wishes to hasten the dissolution, and the other injection fluid is used where the glands have already become soft, as is the general course of such tumors. These formulas are as follows:

Olive oil	70	parts
Ether	30	parts
Creosote	3	parts
Guaiacol	1	part
Iodoform	10	parts

Camphorated naphthol	2	parts
Glycerin	12	parts

The second mixture must be well shaken up for a minute and a half, and injected immediately, as it is very unstable.

These two liquids suffice for all requirements. The indications for their respective use are: as a general rule inject the first, (oil). The second (camphorated naphthol), is to be reserved for cases in which the contents of the abscess cavity ​comprise grumous particles, blocking the needle; in such case, two or three injections of camphorated naphthol will soften and liquefy the grumous material, after which we return to the oily liquid.

The quantity to be injected is the same for both liquids, viz., from 2 to 12 grammes, (half to three drachms) according to the age of the subject, and the size of the abscess cavity. If we are dealing with quite a small abscess of less than 20 c.c. capacity, which is nearly always the case here, we inject twice less liquid than withdrawn pus.

Of equal importance is a suitable aspirator, the all-glass syringe, illustrated here, is the usual style, or the metal syringe, either of which can be sterilized by boiling, are the best adapted instruments. In addition to the above, a tube of chloride of ethyl for local anæsthesia, some tincture of iodine to sterilize the skin, and antiseptic dressings are all that is required. Dr. Calot gives the following technique for the operation:

When should the punctures be commenced? As soon as fluctuation is clearly perceived. In carrying out these operations there are two particular recommendations, viz., to proceed with the utmost cleanliness and only to use very fine needles; be very clean and make sure that your hands as well as the skin of the patient, the instruments, the liquids to be injected, and the final dressing are aseptic. Only use very fine needles, instead of the customary big trocarts, not bigger than 1.5 millimetre external diameter, and always pierce healthy skin at a distance of two or three centimetres from the abscess, so that the two orifices of the skin and the abscess, may be separated by a long oblique canal, and at each puncture pierce the skin in a fresh place.

As to the number of punctures: several will be necessary, (as a rule seven or eight) because a cure is much more certain than with one single puncture. The puncture should be made at intervals of five or six days. After the seventh or eighth ​sitting the walls of the abscess cavity are healthy, and refreshed enough to allow of our devoting our attention to the apposition.

With this object in view, at the next sitting, after making a final puncture without injection, pressure is applied to the region with crossed strips of wadding (see illustration) kept in position with one or more crepe bandages.

This dressing is left off on the fifteenth day. The suppurating gland is cured. The duration of the treatment is therefore from 6 to 8 weeks on an average.

Please note that this complete, absolute cure is not the exception, but practically the rule.

As soon as you have become fairly familiar with the details of this method which, although rather minute, presents no actual difficulty, you will find that recovery, without scarring, takes place invariably, or nearly so, that is to say, ninety times in every hundred, and this in cases when surgeons who had been consulted, declared an operation unavoidable.

It has already been stated that the enlarged glands stand a fifty per cent. better chance of undergoing resorption, if we assist matters a little. We therefore imbue the patient with the necessary patience and in the meanwhile provoke, or promote, this resorption by every means at our disposal; residence in the country, and if possible at the seaside, a course of balneological or hydrotherapeutic treatment, the administration of ​drugs, known to be used in tuberculosis, X-ray, etc., and adding a few injections of creosoted iodoform oil, taking care not to overlook the aseptisation of the whole of the territory discharging into the affected glands, more particularly the toilette of the mouth and teeth. Under these conditions, you will very often, indeed most often, see these glands disappear in the course of a few months.

If it does not disappear, the enlarged gland will, in the long run, soften, which is after all, a mode of cure.

We will be on the lookout for this softening, in order to intervene at once, before the skin has had time to become damaged. Thereupon by punctures and injections, you will cure your patient without leaving any mark.

​I only recognize one really troublesome contingency in practice, and fortunately, this is exceptional, viz.: cases in which the state of the enlarged gland does not change, and shows no tendency in one direction or the other, in spite of our patience; of repeated injections of creosoted iodoformic oil, in which it does not undergo either resorption or softening, cases in which one or more glands remain of pebble-like hardness, suggestive of lymphadenoma, (while on this point you are, no doubt, aware that nearly all the glandular tumors of the neck labeled lymphadenomata are actually cases of tuberculous adenitis).

Here we may appear to be thrown back upon the operation, that is to say, to the inevitable and lifelong cicatrix. Oh, why does this obstinate gland remain hard? Why does it not suppurate? But the gland declines to suppurate. Well, is it not possible to constrain it to suppurate? Can we not oblige this obdurate gland to break? Evidently, if we can do so, we shall be able by puncturing it forthwith, to avoid the operation and the scarring.

This is the problem (of the artificial softening of these local tuberculous masses) which we were the first to raise, to study and finally to solve. This question of general pathology, we may be permitted to remark, was not free from difficulty, because it was necessary to act energetically on the tuberculous gland (since we had to make it pass from the solid to the liquid state) but also with extreme precision, in that the action had to be limited to the gland leaving the skin intact, without ulceration, and without visible trace. In the course of our researches we tried pretty well everything; the local application of all the so-called dissolvent agents; all the internal treatments recommended as likely to provoke the resorption of hard glands; breaking up the gland with needles in order to bring about the softening and ultimate resorption, but all these devices proved unavailing.

Intraglandular injection of every possible substance, including tuberculine, pepsine and pancreatine, in the hope of dissolving or digesting the glandular parenchyma, etc.

​ ​Ultimately, what we found most satisfactory and most effectual, a means that realized our ideal, (the melting of the tuberculoma, leaving the skin intact) was to inject into the hard gland, or tuberculoma, from eight to ten drops of our "four fluid dissolvent," which is as follows:

Phenol	1	dr.
Camphorated naphthol	1	dr.
Sulphoricinated phenol (at 20 per cent.)	1	dr.
Essence of turpentine	1	dr.

This is how it is used: With a hypodermic syringe, you inject from six to ten drops of this mixture into the center of the gland; after two days, five or six drops again. Two days later (that is to say, four days after the first injection) you will find fluctuation, and you may puncture. The fluid withdrawn in viscid, and of a mahogany color.

You are now confronted by a suppurating gland, which is to be treated in the manner described above; puncture and injections. But thenceforth, do not inject anything but glycerinated, camphorated naphthol, say, once every five or six days. In this way, you will still manage to achieve a cure without scarring.

It is to be noted, as you may have surmised, that this softening of the gland does not take place without a rather sharp local and constitutional reaction, comparable with that of a "hot" abscess, or rather of a tepid abscess, in course of formation. The patients must be forewarned of this reaction, which is desirable, and is deliberately provoked.

For this matter the reaction is "regulatable" easily enough, and will subside as soon as the softening has taken place, especially after the first puncture.

Should there remain some indurated points, they must be dealth with by fresh dissolvent injections, but without pushing matters to the extent of trying to get rid of the ​tiniest vestiges. These vestiges may be left, for they will disappear, in the long run, completely or nearly so, by progressive sclerosis.

There is no difficulty when the induration only bears on a single gland, but if the tumor be polyglandular, as in the case of the big young man, (Figs. 1 and 3) this large tumor must be attacked in portions, successively, piece by piece.

In the particular case under consideration, the treatment of each lobe took two months, which make eight months for the entire treatment. You have, however, seen the ultimate result we obtained by our injections, (see figs. 2 and 4).

This case, in itself so instructive, is also interesting from another point of view, as it shows it is not absolutely necessary in order to soften a hard gland to find in its center a focus of caseation, the initial formation of a cavity.

Happily a cicatrix in the neck is vastly easier to prevent than it is to remove. It can always or almost always be avoided by the treatment which I have just described. This treatment no doubt demands a certain minuteness of application, plenty of perseverance, it makes far greater demands on our time than the rapid, brilliant but bloody intervention; yet the latter leaves an indelible mark while our treatment cures without a trace. To cure adenitis without leaving a mark seems to me to be well worth a little extra trouble on our part.

While this book is going to press, word comes from Europe that Dr. Wassermann, of Berlin, and Prof. Ehrlich, of Frankfort, who, for a long time have pooled their forces in a search for an inoculative treatment for cancer, have succeeded in curing this disease, in mice, by a series of inoculations with eosin and selenium. The full details of this treatment are at present unavailable, for no doubt, they have not been perfected, and their experiments have only been confined to mice tumors, which bear a close relation to the ear​cinoma of man. The most they will say, thus far, is that it is possible that they will come upon some help for human beings in the course of their research; and the word "possible" from the lips of such men as Ehrlich and Wassermann, comes with weighty significance, and it is hoped that they have developed the long-sought means of destroying these growths, and with that development, advanced another step towards the goal represented in the prophetic saying "the last enemy that shall be destroyed is death."

No doubt this condition, when present, is of great advantage, and much facilitates the complete liquefaction of the gland, under the influence of our dissolvents, but it is not altogether indispensable, and need not, a prior dissuade us from commencing the treatment. It did not exist in this case, yet complete recovery was obtain.

Although we have previously discussed the plaster treatment from time to time, some physician will come forth with a secret cancer remedy, and in order that the reader may become familiar with these treatments, I will append several formulas which have made fame and fortune for the originators. It will be observed that chloride of zinc and arsenious acid are the active drugs in most of these plasters.

This practitioner obtained a wide celebrity throughout Italy by the use of a preparation which he claimed to be a specific cure for cancer, providing that the growth was accessible, and that the system was not already too deeply implicated in the cancerous cachexia. The formula he usually employed, although it differed somewhat in the relative proportion of the ingredients, was the following:

​

Zinei chloridi	1	dr.
Auri chloridi	1	dr.
Antimonii chloridi	1	dr.
Brominii chloridi	1	dr.
Farinae and acqua	q.s. to separate form a thick paste.

To be applied on small portions of linen to the ulcerated surface.

The essential element he regarded was the chloride of bromine, the quantity of which he often increased to two or three drachms. The chloride of zine was used chiefly for its hemostatic qualities, and be increased this ingredient when there was a marked tendency to hemorrhage. The pain of the application is considerable, and must be allayed by opiates. The application need not remain on more than twenty hours, and may then be replaced by an emollient cataplasm. About the eighth day the eschar should become detached and leave a healthy granulating surface. If any points remain of less satisfactory appearance, or still presenting cancerous ulcerations, a little of the caustic paste is again to be applied. Dr. Landolfi believed it best, though not in all cases indispensable, to administer the chloride of bromine internally in doses of one-tenth or one-twelfth of a drop, in pill form, twice a day, for three to six months.

Hydrarg. chlor. cor.	1	part
Acid arseniosi	2	parts
Hydrarg. sulphuret, rub.	10	parts
Ammonium mur.	10	parts
Farini trit.	120	parts
Amyli	120	parts
Zine chlorid, erys.	120	parts

​

Acid arseniosi	1	part
Spts. vini rect	75	parts
Aqua dis	75	parts

Mix, spread over the parts each day with a brush, until the entire cancer has sloughed off.

The following is the formula of Cosme's Paste as modified by Herba:

Acid arseniosi	1	part
Hydrarg. sulphuret rub	1	part
Ungt. aq. rosae	40	parts

Acid arsenious	1	part
Morphine sulphate	1	part
Calomel	8	parts
Pulv. acacia	48	parts

Dr. Hue uses the following formula hypodermically:

Acid arsenous	1	part
Cocaine hydrochlor.	5	parts
Aqua dist.	500	parts

Mix, inject into the substance of the cancer every few days. This treatment he employed in the treatment of internal cancers, where it seemed impossible to apply the plaster.

​

For several years a man named Davisson resided near Lake Zurich, Ill., who established quite a reputation as a cancer specialist. The following formula is said to be the correct recipe for his plaster.

Rochelle salts	1	oz.
Sulphur	1	oz.
Sulph zine	1	oz.
Arsenous acid	1	oz.

White wax	1	oz.
Fir. balsam	1	oz.
Chromic acid	1	oz.

Melt the wax and the balsam together, and add the acid slowly, stirring while cooling. Remove the cuticle by blistering if necessary, and apply the plaster, spread upon thin muslin. When a sufficient depth of tissue has been destroyed, slough out with poultices if necessary.

A physician recently canvassed this country, selling a cancer cure under the above name, for the formula of which he charged from ten dollars up. Out of curiosity, I purchased the formula, which was as follows:

Zine chloride	½	dr.
Arsenous acid	1	dr.
Powdered sanguinaria	1	dr.
Flour and water	q. s. to make paste

In Southern Illinois a cancer cure has been extensively sold in a similar way, under the name of

​

Chloride of zine	1	dr.
Powdered blood root	1	dr.
Pulv. charcoal	1	dr.
Aqua	q. s. to make a paste.

While the above formulæ possesses a certain degree of merit it only illustrates "what fools we mortals be," who pay from ten to twenty-five or more dollars for a name and receive formulæ which are the common property of the medical profession.

Arsenous acid	1	oz.
Vegetable charcoal	1	oz.
Powd. serpentaria	1	oz.

Mix. Make into a thick paste with water and apply.

This formula was held a secret for many years:

Acid arsenous	1	dr.
Powd. sulphur	1	dr.
Peucedanum off.	1	dr.
Ranunculus sylvestris	1	dr.

Mix. Make into paste with water.

Acid arsenous	1	dr.
Morphine sulphate	1	dr.
Mercurous chloride, mild.	1	oz.
Powd. acacia	6	dr.
Aqua	enough to make paste.

​

Acid arsenous	1	dr.
Mercuric sulphide, red	3	dr.
Vaseline	3	oz.

Zinc chloride	5	gr.
Alum	5	gr.
Acid tannic	2	gr.
Persulphate of iron	3	gr.
Glycerine	q.s. to make paste.

Acid salicylic	10	gr.
Powd. starch	2	dr.
Zine oxide	2	dr.
Lard	4	dr.

Sanguinaria pulv.	1	part
Galangal pulv.	3	parts
Zine chloride	q. s. to make paste

There are several other formulæ of cancer plasters which could be added, but it would only be a repetition of those already given, somewhat modified, and by publishing them would not offer a means of broadening our knowledge on the subject, as what has been said will allow you to treat cancers as successfully as any specialist who holds his methods a secret.