Part 3

Under this methodical procedure the relative value of drugs apparently indicated in these diseases gradually became better known; some, although presenting many and varied symptoms, were found by experience to be superficial and evanescent in their action, while others proved of the greatest efficacy in the most serious lesions, and became indispensable in the armamentarium of the physicians of the hospital staff.

In the latter group, rhus tox. speedily assumed prominence as a drug of special value in ocular disease, and this was enhanced by such a large measure of success in its application over a wide range of affections that it came to be regarded (at least in this hospital) as a veritable sheet-anchor in ophthalmological work, and as time passed it was used more or less in almost all the acute diseases to which the eye and its adnexa are subject.

A prominent symptom of rhus is great swelling of the eyelids. This it has in common with a number of other remedies, but differentiation becomes less difficult when we remember that rhus is specially indicated when swelling and œdema of the lids are the result of the deeper and more serious lesions. After the operation for cataract, one of the first symptoms indicating danger is œdematous swelling of the lids, and no drug in the materia medica compares with rhus for insuring the safety of the eye. When the pathological process becomes advanced, even to the appearance of pus within the eyeball, still we may confidently rely on this remedy, which has cured many such cases when they were apparently hopeless. In all postoperative complications it is of the greatest value, and too much emphasis cannot be placed upon this statement.

When a sound eye takes on sympathetic irritation from its diseased fellow, the fact is first manifested by a certain amount of swelling of the lids and more or less profuse lachrymation, the latter another valuable indication for rhus tox. In this condition I have personally used it many times with complete success, and it is the first drug to be thought of in this extremely dangerous complication.

It is a well-known fact at the present time that rhus is particularly applicable in rheumatic conditions, especially where these are resultant upon a wetting or exposure to dampness. This, together with its nightly aggravation, points to another sphere of usefulness in rheumatic iritis, where it will prove all-sufficient when the characteristic symptoms exist. In suppurative iritis and cyclitis it is very serviceable, no matter what the cause.

The symptom “while he turns the eye or it is pressed, the eyeball is painful, can hardly move it,” indicates its use in acute retrobulbar neuritis, which causes this symptom exactly and is well known to be frequently due to a rheumatic diathesis. The same symptom may call for its use in tenonitis, in which the stiffness, difficulty of and pain on moving the eye are specially prominent and which also has swelling and œdema of the upper lid, chemosis of the conjunctiva, and protrusion of the eyeball; all symptoms of rhus tox. The idiopathic form of this disease is almost always rheumatic or gouty in origin, furnishing still another indication for the remedy. In orbital cellulitis we have swelling of the lids, chemosis, protrusion of the eyeball, almost complete abolition of motion with pain on the attempt and also on pressure, aching in and around the eye, with the probable formation of pus in the deeper structures, all conditions curable by rhus tox., which is one of the best remedies for this disease whatever may be its origin, traumatic or otherwise, and has cured many of the most desperate cases.

In panophthalmitis, or suppurative inflammation of the eyeball, we find the swollen lids, difficulty of, and pain on motion, chemosis of the conjunctiva, severe pain in the eyeball, lachrymation, etc., again indicating the remedy. Rhus tox. is one of the few drugs that have cured this most fatal of lesions, and its success in restoring the integrity of the eye, in some cases where this result has seemed almost impossible, is a matter of record.

The symptom “heaviness and stiffness of the eyelids, like paralysis, as if difficult to move the eyelids,” would seem to indicate its use in ptosis, and this condition as well as paralysis of certain of the ocular muscles, is curable by rhus tox., especially if due to wetting or dampness. Such cures have been made frequently in the clinics of the Ophthalmic Hospital. Erysipelas of the eyelids often presents the characteristic symptoms of rhus. Of course the swelling of the lids is always present, but many of these cases have in addition the chemosis, hot lachrymation, the characteristic pains and aggravation, restlessness, vesicular eruptions, etc., and it is a valuable and efficient remedy when these exist.

Although rhus tox. is specially useful in the most serious inflammations of the deeper and more important structures of the eyeball and surrounding tissues, its sphere is not confined to these conditions alone, but seems to cover almost all the acute diseases to which the visual organs are subject. Given a rheumatic origin, especially if it be from exposure to damp or wet weather, with profuse lachrymation (pain in and about the eye) a tendency to chemosis of the conjunctiva, œdema of the lids, photophobia, and the characteristic aggravation and restlessness at night, and this valuable drug will rarely be found wanting in any of the inflammations of the conjunctiva, cornea, or lids.

I have many times cured with it acute catarrhal conjunctivitis, phlyctenular conjunctivitis and keratitis and ulcers of the cornea, and have subdued the acute aggravations of conjunctivitis trachomatosa, where the above symptoms, or some of them, were present. It is also frequently successful in the treatment of abscess of the lid, which, while not a serious, is an extremely painful disease.

Dr. W. A. Phillips, in an article published in the _Jour. of Oph., Otol. and Lar._, July, 1899, page 224, recommends the use of rhus tox., “when the ciliary muscle itself seems to be the special seat of trouble; when its muscular tone is disturbed from previous straining, and when inability is present after using the eyes for reading any considerable time, notwithstanding optical correction.”

He has had much success with the drug in these cases and considers that its action here is on a plane with that on lameness or soreness due to rheumatism. In my opinion another factor may be spoken of. One of the differential points between arsenic and rhus is that the arsenic patient is _actually_ so weak that he cannot do what he would wish, while the rhus patient _feels_ so weak that he cannot do it, but by making the effort he can overcome his weakness and accomplish what he desires. This seems to indicate in the rhus case an indisposition to exertion due to want of _tone_ of the muscular system, and this explanation applied to the ciliary muscle would account for the successful action of this drug in the class of cases indicated.

I would not have it understood that I consider rhus tox. an universal panacea for all the inflammatory diseases of the eye; all of these affections are many times extremely variable in their presenting symptoms and other remedies are frequently called for, but the drug under consideration is one of the first importance and is most reliable and efficient when accurately prescribed.

TREATMENT OF SARCOMA WITH THE MIXED TOXINS OF ERYSIPELAS AND BACILLUS PRODIGIOSUS.

BY A. WORRALL PALMER, M. D., NEW YORK.

The numerous modes of treating sarcoma or any other variety of cancer, and the constant experimentation on the part of the profession with new methods, only go to show how inadequate is our ability to meet this intractable disease.

These neoplasms are not so rare, as there are ninety-nine authentically recorded cases, situated within the restricted domain of the naso-pharynx and pharynx.

For these reasons, and because I have been able to find only one case of sarcoma treated with Coley’s fluid reported in our homeopathic literature, do I take the liberty of occupying your time with the _résumé_ of my investigations into the subject and my meager practical experience.

Although surgery is, at present, the best method to meet this condition, personally I believe that more investigation into or trials of the remedial treatment should be made, because cancer is a constitutional disease, and it so very frequently recurs after removal with the knife.

Apropos to this, C. Mansell Moullin says in the Boston _Medical Journal_: “There is at least as much hope after an internal remedy that causes disappearance by atrophy or fatty degeneration as from the most extensive removal by operation. On _a priori_ grounds there may be even more.”

Among the numerous drugs or substances which have been experimented with are the interstitial injection of alcohol 40 per cent., by Haase; the injection of Pure Yeast Ferment, by De Bracher; subcutaneous use of 50 per cent. solution of the fluid extract of chelidonium majus re-enforced by same drug per orem; the cataphoric diffusion of mercury from gold electrodes used by Massey; and lastly the mixed toxins of the streptococcus erysipelas and bacillus prodigiosus.

From my research the last is the only one that has attained any success or wide reputation and not been relegated to the usual oblivion of other medical fads. The reason for this I consider to be because Dr. Coley has not only been persevering, but scientific, unbiased, and very cautious in its advocacy. At first he hoped and believed that in some form it would be beneficial in all forms of cancer; but he now only recommends it in sarcoma, and claims marked results only in the spindle-celled variety of this.

As in many other cases, the discovery of the influence of erysipelas on sarcomatous growths was by investigation founded upon accidental occurrences, to wit: Busch reported a case of multiple sarcoma of the face cured by an attack of facial erysipelas; Durante, a sarcoma of the neck; Biedert, an enormous round-celled sarcoma, including the mouth, nose, and pharynx; Bruns, a melanotic sarcoma of the breast; Gerster and Bull, each a recurrent sarcoma of the neck; all cured or disappeared with no return, after an erysipelatous attack. This happy result does not always follow erysipelas, as cases of sarcoma relieved by erysipelas, and later recurring or progressing after the attack is over, are reported by Busch, Nelaton, Deleus, Richochon, Winslow, Powes, and Dowd.

On account of these accidental cures a few observers produced erysipelas artificially by infusion with the living culture, with success in many cases.

Then almost simultaneously Lassar of Berlin, Spronck of Utrecht, and Coley of New York, believing that the curative action of erysipelas lay in the toxin of the living culture, experimented and found that they could produce equally good results with toxin, thereby avoiding both the danger and discomfort of the patient passing through an attack of erysipelas.

It has been shown by different observers that the combination of certain bacilli with disease toxins makes such toxins more potent, and Rogers of Paris demonstrated that the combination of the bacillus prodigiosus with the streptococcus of erysipelas greatly augmented the virulence of the streptococcus on rabbits. Thereupon Dr. Coley used the combination on the human subject in sarcoma with far better results than before.

Regarding this, Dr. Coley says he cannot say exactly what part the bacillus prodigiosus plays in the cure of sarcoma, but remarks that the only cases cured were treated by the combination.

This preparation, the combined toxins, had been given the name of Coley’s fluid, and that used during the last seven years has been made by Dr. B. H. Buxton of Loomis Laboratory.

Until about five years ago the toxins were made from cultures from a fatal case of erysipelas, but since that, sufficient strength has been obtained by passing the cultures through about fifty rabbits. The method of the preparation is virtually this: the mixed unfiltered toxins of the streptococcus of erysipelas and the bacillus prodigiosus are made from cultures grown together in the same bouillon and sterilized by heating to 58 degrees C. and then diluted in a sterilized menstruum.

In a recent conversation with Dr. Buxton he said that at present he made a double sterilization and then added some drugs such as thymol to preserve the preparation.

Dr. Coley, in his exhaustive article in the _Jour. Am. Med. Assoc._, August 20 and 27, 1898, affixed a table of fifty-seven cases of cancerous tumors treated with either his fluid or other preparation of erysipelatous poison with cure, or at least disappearance of the then present manifestation of the disease and lengthening of the usual period of a recurrence of the condition.

The following is a list of cases of sarcoma of the nose and throat treated by cultures of erysipelas, or Coley’s fluid, the physicians in charge, and the time the patient is living after treatment at the time of the report in Dr. Coley’s paper, in 1898:

(a) A spindle-celled sarcoma of the neck and tonsils, inoculated culture—patient living six years after.

(b) A spindle-celled sarcoma of the parotid; it had been extirpated twice previous to treatment—patient living one year after.

(c) A sarcoma (mixed celled) of the parotid—patient living three years after. The foregoing under Dr. Coley’s care.

(d) A spindle-celled sarcoma of the palate and pharynx extending to the vocal cords—Dr. W. B. Johnson—living four and three-quarter years.

(e) A round-celled sarcoma of antrum, pharynx, and neck—Dr. L. L. McArthur—child aged five years, weight gained from 37 to 69 pounds—later, fatal recurrence.

(f) A round-celled sarcoma of parotid, size of the fist—Czerny of Heidelberg—living over a year.

(g) A spindle-celled sarcoma of the parotid—Horace Packard—living two and three-quarter years.

(h) A round-celled sarcoma of the neck—H. Montague—slight return in six months.

(i) A recurrent sarcoma of the neck and tonsil—J. O. Roe—six months after treatment died of erysipelas.

The mode of administration is cumulative. The injection is of course to be made under the most thorough antiseptic principles attainable. It is by far preferable to make the injection into the growth itself, although, if this is impossible, it may be introduced into the nearest accessible point, but in the latter case the dosage needs to be doubled.

As a rule one-half drop is the initial dose, and this is increased one-half drop each succeeding day until toleration is reached. This is evidenced by the natural reactionary fever rising to 102° or 103° F. In such case the following dose should be the same as the preceding, and if it should again go so high reduce the next dose one-half drop. The dose is increased in this manner until the maximum is attained. When applied to the neoplasm itself 8 drops is the full dose, or if elsewhere, double that amount, 16 drops.

This last amount is to be continued daily until the tumor has disappeared.

The toxin may commence to reduce the tumor in a week, but its administration should not be abandoned in less than three weeks’ trial. The time necessary to effect a cure is very variable; occasionally the neoplasm will almost disappear in two weeks, while on the other hand it may take several months.

The reactionary symptoms are a chill, followed by fever, generally lasting about three hours, although occasionally it may continue twelve hours; acute transitory swelling of tissues in the immediate vicinity of injection; usually myalgic pains commencing at point of injection and radiating frequently over the whole body; in the more severe reactions there is nausea or even vomiting—in my own case it produced a weakening menorrhagia.

CASE.—Mrs. E. C., æt. thirty-four years. A tall, thin woman of neurotic temperament.

_Family History._—Father had chronic bronchitis, but died of kidney disease. Mother was an invalid for seven years with rheumatism of hip and knee until death, which was caused by apoplexy; a sister died of gastric disease. The patient married eleven years; has two children living; boy at nine months died of entero-colitis; boy three and one-half years died of fall from window; two miscarriages. At ten years æt. the patient had diphtheria; at twenty-six, pleurisy; at thirty-one years, rheumatism of left shoulder and post-cervical region. It is impossible to obtain any indication of hereditary predisposition.

_Subjective Symptoms._—Complains of post-nasal dropping of mucus, constant short hacking cough, malodorous breath, pain in region of spleen; aggravated when lying down and throbbing in character when walking rapidly. After discovering the swelling in the throat and speaking of it she admitted there had been a sensation of a lump in the throat for about a year, but so slight she considered it of little consequence.

_Objective Symptoms._—Nares: Rhinitis sicca, covered with dry crusts, but turbinated bodies hypertrophied.

Naso-pharynx and pharynx: Mucosa slightly hyperæmic, follicles inflamed and enlarged. On the left side of these cavities is a sessile swelling, the general surface of which is much inflamed, and half of the surface is covered with varicose veins about one-eighth of an inch in diameter; it extends more than half the width of the pharynx and vertically from the vault above to the lateral sinuses below; is neither painful nor hyperæsthetic; it has a boggy feel, but not as soft as an abscess. The tumor springs from the posterior wall of the pharynx, not connected with the tonsil, as the left posterior pillar lies in front of the neoplasm and can be lifted free from it. Neither of the tonsils is inflamed nor hypertrophied; a few cervical lymphatics on the left side are slightly indurated, but slightly sensitive—if at all.

The swelling had probably existed longer than an abscess would be in forming, and there was neither pain nor fluctuation. Still an exploratory incision was made, but with the expected negative results.

Although the tumor was situated over the principal chain in lymphatics of the pharynx, it was not nodular, but smooth. Therefore the neoplasm was probably not of lymphatic origin, but an implication of the muscular tissue behind the pharynx.

A specimen was submitted by Dr. Klotz, the pathologist of the hospital, and the provisional diagnosis of angio-sarcoma made—sarcoma because it seemed to spring from the muscular tissue and apparent predominance of blood-vessels, and of the angiomatous variety because of the enlarged blood vessels on the surface.

The removal of the specimen for microscopical examination caused quite a severe hemorrhage, lasting about two hours, notwithstanding the employment of the usual hemostatics.

The microscopist pronounced it a small round-celled sarcoma.

I showed the case to the Academy of Pathological Science, where two general surgeons who examined the case advised against extirpation of the tumor, because of its close proximity to the important blood vessels and nerves of the neck, an opinion I entirely coincided with, because of seeing two similar cases before. This agreement decided me in determining to try the mixed toxins as the treatment promising the best results for the patient.

April 4. Commenced injections with one-quarter of a drop. I diminished the initial dose one-half because Dr. Coley personally advised it, as he thought the possible reactionary local swelling might seriously interfere with respiration.

April 14. The dose was increased one-quarter drop each day to date—when she took only two drops, because it was deemed advisable to omit treatment two days during menstruation on account of great weakness of patient.

April 20. Increased dose half drop per diem—on 16th and 19th treatment omitted on account of debility—dose 4 drops, which dose was continued till April 23, when on account of the temperature twice having risen to 103° F. and menorrhagia having supervened only ten days after previous regular menstruation, I thought it prudent to reduce dosage to 3½ drops, which was continued until April 26. Examination of pharynx to-day for first time showed a decided diminution in the congested appearance and size of the tumor. Formerly the tumor pushed the posterior pillar forward, so that, if the pillar could not have been lifted away from swelling by the ring probe, it would have seemed to be part of it; while to-day a small space could be distinguished between the tumor and the pillar. Dosage 4 drops.

In _résumé_, I would call attention to the apparent susceptibility of the patient to the toxin. Because, although she never received over half the maximum dose, the following reactionary symptoms developed: Of the seventeen days on which full records were kept, on thirteen she had chills after every dose; there were muscular pains throughout the left side, occasionally extending to the right—one-third of the time the patient was nauseated, and three times vomited—the average temperature was 100.8° F.; twice it did not rise at all after injections of ½ or 2½ drops. ’Tis well to bear in mind that chills very seldom occur after the third injection.

Finally, I wish to thank Dr. Clausen, resident physician, who carried out most of the treatment while the patient was at the Ophthalmic Hospital; also Dr. Bernard Clausen, who continued it after she returned home.

REPORT ON “HENPUYE” IN THE GOLD COAST COLONY.[3]

BY ALBERT J. CHALMERS, M. D., VICT., F. R. C. S. ENG.

Henpuye, or dog nose, is a disease frequently met with in the Gold Coast Colony and in certain portions of its Hinterland. The hideous deformity of the face which it causes is very striking to anyone who has lived in this part of West Africa. It is also known on the French Ivory Coast under the name of “goundu” or “anakhre,” but “henpuye” is the native name (Appolonian) for the disease on the Gold Coast. The peculiar nature of the disease and the fact that, as far as I could find, very little was known as to its nature led me to make the inquiries which are now embodied in this report. I regret very much that I am unable to refer to original papers on the subject or to be certain that I have the full literature, but my excuse is that libraries do not exist in West Africa. The only references which I have met with are those mentioned in Dr. Patrick Manson’s work on “Tropical Diseases” (p. 594), and they are those of (1) Professor Alexander Macalister (Royal Irish Academy, 1882), (2) Surgeon J. J. Lamprey, A. M. S. (_Brit. Med. Jour._, vol. ii., 1887), (3) Dr. Henry Strachan (_Brit. Med. Jour._, vol. i., 1894), and (4) Dr. Maclaud (Archives de Médecine Navale, 1895). It is by the kind permission of the Governor of this colony, Sir Frederick Hodgson, K. C. M. G., that I am allowed to publish this report. I am much indebted to Captain Armitage for his kindness in giving me information with regard to the different places in which he has noticed this disease in his travels, for drawing my attention to notes of the late Mr. Ferguson on the presence of the disease in Akim and Kwahu, and for making a painting of an advanced case of the disease; also to Dr. Henderson, the chief medical officer of the colony for many kind suggestions: and, lastly, to Mr. Crowther, draughtsman in the Public Works Department, for supplying me with a map of the colony and its Hinterland. The description of the disease will be divided into the following headings: (1) the General Description of the Disease; (2) the Description of Cases of the Disease; (3) the Treatment; (4) the Morbid Anatomy; (5) the Ætiology; and (6) the Geographical Distribution.