282 inflamed. 12 It is, however, rare for such predisposing con- ARSENIC CANCER: ditions to be effectual in breaking down the natural cancer A Case under the Care of resistance of the tissues, unless these are comparatively senile. So that the somewhat early age of many of the W. HARWOOD NUTT, M.D., CH. B. EDIN., subjects of arsenic cancer seems, not unreasonably, to suggest MEDICAL OFFICER TO THE SHEFFIELD UNION WORKHOUSE; HONORARY that the of arsenic in the skin may have MEDICAL OFFICER TO THE X RAY AND ELECTRICAL DEPARTMENT prolonged presence a on to Com. OF THE SHEFFIELD ROYAL HOSPITAL; deleterious influence its resistance cancer, parable with that exerted by senescence. A on the Parts Pathological Report Removed, The injuries just referred to are familiar enough in several BY J. M. BEATTIE, M.A. N.Z., M.D., C.M. EDIN., forms, such as mechanical (as a pipe in relation to cancer of PROFESSOR OF BACTERIOLOGY IN THE UNIVERSITY OF LIVERPOOL; the lips in smokers), chemical (as pitch in relation to cancer HONORARY CONSULTING BACTERIOLOGIST TO THE ROYAL of the skin in briquette makers), actinic (as X rays when SOUTHERN HOSPITAL, LIVERPOOL; over-applied to the skin),13 atmospheric (as sun, wind, and Together with Summaries of 30 other Collected Cases and salt spray in the skin cancer of sailors) (63). Remarks,1 In some other forms the nature of the injury is more un- BY R. J. PYE-SMITH, CH.M. SHEFF., F.R.C.S. ENG., certain, as that inflicted by soot in the development of cancer of the that caused CONSULTING SURGEON TO THE SHEFFIELD ROYAL HOSPITAL AND TO chimney-sweep’s scrotum, by THE MONTAGU HOSPITAL, MEXBOROUGH; EMERITUS PROFESSOR phimosis in the production of cancer of the penis, that pro- OF SURGERY IN THE UNIVERSITY OF SHEFFIELD. duced by cutaneous horns when ending in cancer, 11 that (Concluded from p. 216.) done by chronic lupus or by Paget’s disease of the nipple, that due to the scars of burns, as in cases of kangri cancer, occurring in Kashmir, where charcoal braziers are worn IN the the summaries of 30 collected cases preceding part over the skin of the abdomen,15 or that present in Kaposi’s of arsenic cancer were In this series there is a remark- given. disease (xerodermia pigmentosa) in its final cancerous able in of their features. In all of similarity many nearly stage. In other cases, again, the irregular growth incident them arsenic had been taken for over periods extending to advanced age seems to take the place of injury to the years, and in nearly all hyperkeratosis.was present, especially skin. in the palms and soles, and of a type often produced by In certain instances of some of these kinds of skin cancer arsenic. In half the cases the cancerous lesions fully a local condition of keratosis, often accompanied by desqua- were multiple, a fact strongly suggestive of the presence mation and pigmentation, and followed by fissure and of some and unusual or general predisposing exciting ulceration or by ulceration without fissure, commonly pre- cause. In a fourth of the cases the of the age cedes the onset of malignancy. The same is true of nearly patients did not exceed 35 years, again suggesting all the cases of arsenic cancer. It looks as if arsenic induces some cause.ll In several of the cases the use of special keratosis of the skin (as is now universally admitted),16 the arsenic had been discontinued for many years before the keratosis mechanically inducing fissures, which readily cancerous changes set in, pointing to its being an early or become infected with bacteria and then ulcerate, the ulcers remote rather than a late or final cause. In most of the finally becoming cancerous.17 cases the epitheliomatous process (which always began in The late Sir Jonathan Hutchinson repeatedly suggested that the to have started in a of in skin) appears patch keratosis, arsenic may possibly be a causative factor in forms of cancer a few cases in not apparently (though probably really) in which it has not hitherto been suspected ; and so widely in a normal skin, seldom, if ever, patch of psoriasis, is this metal distributed in nature as to lend countenance to that the last-named in two- showing disease, though present the suggestion, for its occasional ingestion through food or thirds of the not a causative factor. In cases, was probably water must be possible to nearly all races of men and to one-fifth of the cases is mentioned. only pigmentation many animals. Arsenic is present in many soils and, in Lesions were situated on the the upper extremity (usually traces, in many natural mineral waters. It has occasionally hand) in nearly two-thirds of the cases, on the lower ex- been found in certain vegetable and animal tissues, though the in a fourth of the in one tremity (especially foot) cases ; probably it is not a normal constituent of either (66). So instance was the face the rest of the cases only affected, many drugs are liable to contain arsenic as an impurity divided between the trunk with the being nearly equally that it is not easy to say that any manufactured drug will neck and the external with the genital organs perineum. be free from it " (71), and that over 100 official substances The fact of the hands and feet so often affected being and preparations are included in the list for which a suggests that either trauma or the keratosis, so generally maximum contamination is to be fixed in the forthcoming present there, was a determining factor in the localisation of Pharmacopoeia. This list includes salts of ammonia, bismuth, the lesions. In the case recorded the of a principal wearing iron, lime, magnesia, potash and soda, as well as citric and wedding ring appeared to have fixed the site of the primary tartaric acids, glycerine, and glucose (72). ulcer. Although microscopical examination by competent The commonest source of this contamination is to be pathologists was not always conclusive in the early stages found in commercial sulphuric acid, which is manufactured of the cancerous and several of the process, although from arseniferous pyrites. It was the use of this acid in the cases were at one stage suspected to be syphilitic, yet sooner manufacture of invert sugar for brewing that was responsible or later, in almost every case, the microscope has confirmed for the epidemic of arsenical poisoning by beer at Manchester the clinical diagnosis of epithelioma. Excision of the cancerous lesion, or amputation of the affected part of the 12 To use the words of Mr. Victor Bonney, "Epithelial cancer is on a a of limb, was practised in two-thirds of the cases. In many never initiated normal surface, but is led up to by series inflammatory changes in the epithelial and subepithelial connective instances local recurrence followed these operations, and tissues " (62). in about a fourth of all cases metastasis ultimately took 13 See Multiple Carcinomata following Chronic X Ray Dermatitis, by to and internal Death from the disease Dr. Charles Allen Porter, Boston, Mass., with Pathological Report by place glands organs. Dr. Charles J. White, Harvard had occurred in half the cases when were University (59). already they 14 Dr. Hermann Lebert (64) collected the published cases of cutaneous recorded. Three times as many men were affected as horns (109 in number); in 13 of them (nearly 12 per cent.) epithelioma women. developed. See also Cornu Cutaneum of the Human Scalp, by Herman L. Niertert, and Edmund A. Babler, M.D. and Cutaneous to as a M.D., (58), Epithelial cancer appears attack, rule, tissues Horns, by Charles K. Roys, M.D. (60). which have been exposed for prolonged periods to frequently 15 See the account given by Dr. Theodore Maxwell in an article on and have in suffered a Epithelioma in Kashmir (22), and a similar account by Dr. E. F. repeated slight injury, consequence Neve of or become more or less (34a). depression vitality, definitely 16 Romberg (65) appears to have been the first (1851) to recognise that keratosis could be induced by arsenic. Thomas Hunt (20) had 11 But in a valuable paper (61) entitled " The Study of the Etiology of previously (1847) attributed pigmentation, in regions protected by the Cancer, based on Clinical Statistics," Dr. Isaac Levin, of New York, clothing, to the same cause. after analysing 4000 cases of cancer, reported from the hospitals in New 17 Irregularity in the epidermic overgrowth which occurs in keratosis York, Brooklyn, Baltimore, and Philadelphia, found that, although in may perhaps (?) lead in some cases to the segregation of small portions this series cancer generally occurred in persons under 35 years of age of epithelium, and so originate epithelioma before ulceration com- in the proportion of only about 12·6 per cent. of all cases, yet cancer of mences. See The Causation of Cancer, by L. B. Wilson, M.D. (80). the extremities, of which there were 206 cases, occurred in such persons So long ago as 1880 Sir Frederic Eve cited cases which " indicated that in 47 per cent., or nearly as often in those under as in those over the the border line between the so-called hypertrophies of epithelium age of 35. On the other hand, Mr. G. Lenthal Cheatle, C.B., collected (callosities, warts, &c.) and epithelioma was of the slightest description, cases of cancer of the and states a that the and that a continuance of the causes which rise to the former 56 hand, (34) (in private letter) " gave ages of the patients were all over 50.