by Mary W Maxwell, LLB
This article reprints Cases 27 and 28 from “A Review of the Influence of Bacterial Infection…on Malignant Tumors in Man,” by Helen Coley Nauts, George A A Fowler, and Frances Begatko. Abridged and with bolding added.
Case 27: F.H.F male, age 46, structural iron worker of Somerville, Massachusetts.
Case 27: F.H.F male, age 46, structural iron worker of Somerville, Massachusetts. Onset, without known cause: a pigmented mole in the scapular region began to swell early in June 1911. Five weeks later, or on July 14, 1911, Homans excised the growth with a two inch margin of normal skin. The patient was seen every two weeks thereafter and no recurrence was noted until October 22, when a small lump was seen on the outer aspect of the scar. Three days later the patient was admitted to Massachusetts General Hospital, and Cobb excised the recurrence. The patient was first seen by Dr Torr W. Harmer two weeks after this operation, at which time he had another recurrence 2.5 by 0.5
inches in diameter in the second cicatrix, and a palpable mass in the axilla the size of a pigeon’s egg.
Toxin Therapy: (Parke Davis XII). Injections were begun by Harmer on November I5, 1911. No details are given as to the site, dosage or frequency of injections during the early treatment, which did not prevent another mass the size of an English walnut from appearing in the same scar.
The two masses became confluent, but under continued toxin therapy they sloughed out entirely in one month, leaving a thin soft scar. Harmer stated: “During this time, however, a recurrence appeared in the upper scar, which became 31/2 x 3 x 1 inch in diameter. This whole mass was entirely sloughed out by January 13, 1912″.
A pigmented mass appeared in the right pectoral region early in January 1912. It ruptured in three weeks with local injections, but increased in size until it was 3 x 2 inches in diameter. There were several “erysipelatous” attacks when the whole pectoral region would be red, hot, tense and tender, Harmer stated.
A second gland appeared in the axilla and another in the neck The latter became the size of a cherry but disappeared in one month. The axillary masses became the size of a hen’s and pigeon’s egg during these erysipelatous attacks, but within a month decreased considerably and never became any larger until treatment was discontinued 11 months later. The entire breast tumor sloughed out with cutaneous appearance of dark pigment by August 1913 and never recurred.
Harmer stated that one bluish black mass about 1.5 inches in diameter regressed under local injections to an apparently fibrous mass of dull red color about 3/4 inch in diameter. of the former one. During this period another pigmented mass was developing within a few inches
The second mass attained the size of a pigeon’s egg during the time that the treated one was regressing. Both masses were then excised under ether anesthesia, with an elliptical area of skin, subcu-taneous tissue and fascia. Fourteen sections were made from these two tumors. In reporting this case in 1914 Harmer showed characteristic portions of the treated tumor.
By August 1913 the patient was in excellent condition with a good appetite and no evidence of internal metastases. The other masses had sloughed out, or been excised, as stated above. (Note: this case received both Tracy’s XI and Parke Davis XII, mostly the latter. No other case is known to have received as high dosage as this man was given.)
Clinical Course: The patient then disappeared on a “spree”, returning 15 days later, haggard and weak.
Further Toxin Therapy: Injections were resumed, but the patient never regained his former tolerance for the toxins. He had been taking 40 or 50 minims at a dose prior to this spree, but when he returned 4 to 5minims produced as severe reactions as he had formerly experienced only with the larger doses.
New masses began to appear on the abdomen, arms, breast and back. This second course of toxin therapy lasted only from October I, 1913 to January 26, 1914..
Clinical Course: The disease was not control1ed. Death occurred on February 26, 1914, with metastases in the spinal cord and abdomen.
Note: This case indicates the danger of suspending treatment too soon after visible masses have regressed in cases of malignant melanoma with metastases. It is also apparent that any factor which lowers the patient’s general physical condition, such as large amounts of alcohol, or returning to hard physical labor too soon, or any other excessive activity, may throw the balance in favor of the neoplasm, making it difficult or impossible to regain control of the disease.
It appears that a larger quantity of toxins aggressively and persistently administered may be necessary in order to produce results in cases where several metastatic masses are present.
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CASE 28: Inoperable angiosarcoma of the mediastinum, confirmed by microscopic examination by Dr F. S. Mandlebaum, Pathologist of Mount Sinai Hospital. Dr James Ewing also examined the sections and reported: “Malignant cellular tumor of embryonal type, composed of many blood sinuses lined by two or more rows of tumor cells. Very delicate stroma.” He regarded it as an extremely malignant form of tumor.
P. H., female, age 22 months, of New York.
The child had been normal at birth, weighing 9 pounds. She was breast fed for 10 months and she walked at 16 months. She had gained slowly in weight although there had been frequent green diarrheal stools. At the age of 5 months the mother noticed that the child’s breathing was distinctly labored, but the family physician found nothing wrong with the lungs.
For two months there was respiratory disturbance without cyanosis or other sign of deficient aeration. The child was pale and heart action was often rapid. At the age of eight months the mother noticed a “lump on the right shoulder blade” while bathing the child.
She took her to the Babies Hospital, where a roentgenological examination was made. This was reported as showing “a large roughly quadrilateral, dense shadow in the lower part of the right chest, extending over the heart, also the left chest and down over the liver shadow. Right chest above this appears free from lung tissue. The right diaphragm appears free from lung tissue. The right chest is smaller than the left. The right bronchus is not seen. Probably congenital atelectasis.
The mother refused to leave the baby but took her to Lebanon Hospital, where fluoroscopic examination was made, April 30, 1923. This revealed “a dense shadow, homogeneous in character, sharply circumscribed, ascending apparently from the lower mediastinum…. The mass is the size of a small orange…. The appearance is either that of a cyst or a neoplasm ascending from the mediastinum.”
An exploratory operation was suggested but refused by the child’s mother, who took the patient home. At 20 months, tonsillitis developed and the child was taken to Beth David Hospital. On March 16, 1924, when the child was 21 months old, she suddenly stopped walking because of weakness of the right lower extremity, which became rapidly progressive.
At first she was able to stand, but the right foot turned out and she fell on attempting to walk. She was first seen by Dr Alfred V. Pollak at this time, at the Hospital for Joint Diseases. He noted that the patient was a bright, well-nourished child, without fever or pain. There was great weakness of the lower extremities: total inability to stand because of paresis of both legs.
There was a mass between the right scapula and the spine, with dullness on percussion. Breath sounds were exaggerated anteriorly. A blood examination was reported as follows: hemoglobin, 42%; erythrocytes, 3,200,000; leukocytes, 14,000…. Roentgenological examination at this time was reported: “Cyst, lower right chest; pressure erosions, spine and rib, oesophagus is displaced anteriorly”.
Dr Howard Lilienthal was called in to see the case on April 12, 1924, a month after she had stopped walking. He found both legs flccid and obviously paralyzed.
There was a protruding sub-cutaneous mass covered with normal skin between the right scapula and the spine which was firmly elastic. The child’s general condition was good. On April 15, 1924, Lilienthal operated, and the tunor exposed…. He removed grey-ish red soft neoplastic tissue. He then suggested toxin therapy.
Lilienthal operated, at Mount Sinai Hospital. He resected about 1.5 inches of a rib subperiosteally over the tumor.
He then aspirated a minute quantity of thick bloody fluid. The posterior mediastinum was then opened and the capsule of the tumor exposed. This was incised so as to admit the index finger. The wall was tense and the tumor rudely spherical.
Toxin Therapy: (Parke Davis XIII). On April 25, or ten days after this operation, injections were begun by Pollak. The initial dose was one half of a minim, the site being the gluteal muscles. This was followed by a severe reaction.
For 11 days the injections were given daily, increasing the dose to a maximum of 41/2 minims. The febrile reactions ranged as high as 106 0 F. Further injections were refused by the patient’s mother, because of the severity of the reactions. Pollak’s observations as to the effects of toxin therapy are of value: He stated that the intensity of the reactions had been very great, and added:
“From the very first the healing of the operation wound was extraordinary, and after the third injection the progress of the healing was even ten-fold quicker than before, and after the reaction was over the child seemed to be better generally. The hemoglobin count was 42 % at the time of the operation and after the eleventh injection it went down to almost 30%. Because of the violent reactions the mother requested that the injections be stopped, at least temporarily… The child began to walk within three weeks from the first injection, relief being due apparently to decompression.
Intercurrent Infection: During the summer immediately following toxin therapy, the child developed a very severe case of pertussis, there being as many as 14 violent paroxysms in one afternoon. … A severe attack of measles, and then bronchitis followed the pertussis, but the child recovered without any ill effects. It is possible that the severe attack of pertussis, as well as the measles and bronchitis may have generated toxins which helped to continue the process of regression of the neoplasm. The possible effects of contagious diseases other than tuberculosis on malignant tumors in man have not
been seriously considered until rather recently. However, several investigators have reported the inhibitory effects of intercurrent contagious diseases on tumors in mice or rats. Bashford was one of the first to note that mice convalescent from contagious diseases are refractory to tumor transplants.
Clinical Course: The patient’s condition continued to improve…. On September 19, 1926, Philips reported: “There appears to be considerable regeneration of the posterior ribs, which previously showed marked pressure erosions, and considerable regeneration of the resected portion of the eighth rib has taken place.” A month later examination showed a normal chest.
In February 1928 Dr Leopold Jaches examined the patient’s chest and reported: “No evidence of abnormality in the lungs, diaphragm, heart and aorta. The eighth rib shows evidence of previous resection, but it has regenerated almost completely”, (film No. II ,846).
The patient remained in perfect health and was seen periodically by Pollak and Lilienthal during the next 21 years. She was presented at various medical meetings by Lilienthal, who on one of these occasions stated: “My experience with this form of therapy in a number of other instances has been so favorable that I would strongly recommend its use in inoperable sarcoma and also as a prophylactic postoperative treatment after surgical removal of operable tumors as well”. The patient reported in November 1949 that she had had a son, her first child, and added: “The baby was a natural birth and I had a wonderful pregnancy.” The patient was last traced in good health in 1953, or over 28 years after the toxins were begun.
Note: Pollak’s observations of the apparently stimulating effect of the toxins on the rate of healing of the operative wound are of interest, as this effect was also reported by other surgeons using the method, and is apparent in many of Coley’s cases, especially osteolytic bone tumors, where extensive areas of bone destroyed by the neoplasm completely regenerated following toxin therapy.