Leukemia

“ These granules are identical with the corresponding granules in the leukocytes just described. The occurrence of two kinds of granules in the same cell is rare.
Myelocytes are the bone-marrow cells from which the corresponding granular leukocytes are developed. Their presence in the blood in considerable numbers is diagnostic of myelogenous leukemia. The neutrophilic form is the less significant. A few of these may be present in very marked leukocytosis or any severe blood condition, as pernicious anemia. ”

“ They are most abundant in myelogenous leukemia. While always present in pernicious anemia, they are often difficult to find. Megaloblasts are found in pernicious anemia, and with extreme rarity in any other condition. They almost invariably [p. 178] exceed the normoblasts in number, which is one of the distinctive features of the disease. Microblasts have much the same significance as normoblasts, but are less common.
2. The Leukocytes.—An estimation of the number or percentage of each variety of leukocyte in the blood is called a differential count. ”

“ Very constant also is a marked absolute, and often a relative, increase of eosinophiles and basophiles. Polymorphonuclear neutrophiles and lymphocytes are relatively decreased.
[p. 210] The red cells show the changes characteristic of a severe secondary anemia, except that nucleated reds are commonly abundant; in fact, no other disease gives so many. They are chiefly of the normoblastic type. Megaloblasts are uncommon. Blood-plaques are generally increased.
2. Lymphatic Leukemia.—This form may be either acute or chronic. There is marked loss of hemoglobin and red corpuscles. ”

“ Lymphocytes are formed in the lymphoid tissues, including that of the bone-marrow. They constitute, normally, 20 to 30 per cent. of all leukocytes, or about 1000 to 3000 per c.mm. of blood. They are more abundant in the blood of children.
The percentage of lymphocytes is usually moderately increased in those conditions which give leukopenia, especially typhoid fever, chlorosis, pernicious anemia, and many debilitated conditions. A marked increase, accompanied by an increase in the total leukocyte count, is seen in pertussis and lymphatic leukemia. ”

“ Once deadly forms of cancer are now yielding to combined treatments of surgery, radiation, drugs, and new biological agents, such as interleukin-2. A diagnosis of breast cancer no longer requires an inevitable mastectomy. Children with leukemia are being treated successfully and living to become productive adults. ”

“ In myelogenous leukemia there is almost invariably an absolute increase of eosinophiles, although, owing to the great increase of other leukocytes, the percentage is usually diminished. Dwarf and giant forms are often numerous. ”

“ They are decreased in chronic lymphatic leukemia, and greatly increased in the myelogenous form.
(d) In purpura hæmorrhagica the number is enormously diminished.
Blood-plaques are difficult to count owing to the rapidity with which they disintegrate and to their great tendency to adhere to any foreign body and to each other. The method of Kemp, Calhoun, and Harris is practical and is to be recommended:
Wash the finger well and allow a few minutes to elapse for the circulation to become normal. ”

“ Oligocythemia occurs in all but the mildest symptomatic anemias. The blood count varies from near the normal in moderate cases down to 1,500,000 in very severe cases. There is always a decrease of red cells in chlorosis, but it is often slight, and is relatively less than the decrease of hemoglobin. Leukemia gives a decided oligocythemia, the average count being about 3,000,000. The greatest loss of red cells occurs in pernicious anemia, where counts below 1,000,000 are not uncommon. ”

“ Excludes1: acute exacerbation of chronic myeloid leukemia (C92.10) refractory anemia with excess of blasts not in transformation (D46.2-) C92.00 Acute myeloblastic leukemia, not having achieved remission Acute myeloblastic leukemia with failed remission Acute myeloblastic leukemia NOS C92. ”

“ And I saw just the other day, in Mentor, Ohio, where a father told the story of his eight-year-old daughter, whose long battle with leukemia nearly cost their family everything had it not been for health care reform passing just a few months before the insurance company was about to stop paying for her care. [1]
I had an opportunity to not just talk to the father, but meet this incredible daughter of his. And when he spoke to the crowd listening to that father’s story, every parent in that room had tears in their eyes, because we knew that little girl could be our own. ”

“ We must conclude, therefore, that there is some constitutional condition, or rather some state of the blood, which nourishes the cells and which favors this continued malignancy—some fuel which feeds the malignant process and at the same time induces a progressive lowered vitality, ending fatally. For we have already seen in these and former lectures that the local lesion which we call cancer is but one manifestation or result of a pernicious anemia, which, if not checked, may end life in a relatively short time. ”

“ Some have suggested the hypothesis that the mononuclear leukocyte, by conjugation with disturbed cells, gives them an abnormal reproductive power by 67which they eventually develop the tumor and invade other tissues. But back of all this there is still some activating cause, which is found in the fluids which bathe every tissue, namely the blood and lymph, which we shall see later are deranged in cancer.
The fact that with innumerable injuries occurring everywhere and at all times cancer develops from them very rarely, should teach us something. ”

“ The malignancy of cancer depends on the tendency which the epithelium has of invading the tissues in its neighbourhood, and on the capacity of the cells, when transported elsewhere by the lymph or blood-stream, of giving rise to secondary growths.
Cancer may arise on any surface covered by epithelium or in any of the secreting glands of the body, but it is much more common in some situations than in others. It is frequently met with, for example, in the skin, in the stomach and large intestine, in the breast, the uterus, and the external genitals ”

“ As yet we know little or nothing in regard to actual cancer-genesis; no one has ever demonstrated, and probably no one ever will demonstrate, the absolute beginning of the change in some normal cell or cells, in the breast or elsewhere, which eventuates in their taking on the rampant or malignant feature which we call cancer. But this change does occur, and though the exact alterations in the polarity of the cells and the disturbance of their centrosomes and nuclei, which have been described, may not be perfectly understood, there is some definite cause for their occurrence. ”

“ The highest hemoglobin index was 90 in a number of severe cases, and 100 in one case of sarcoma, to be detailed in the next lecture. In one recurrent case of cancer of the left breast, which was very distressing at first, the patient died peaceably and without pain, with a hemoglobin index of 90, and 4,900,000 red cells, and 7,400 white cells, of which 75 per cent were polynuclears, 17 per cent small lymphocytes, and 7 per cent mononuclears. Her hemoglobin had been 70 per cent on entering the hospital with 3,360,000 red cells. ”

“ We now know that so-called secondary cancers are the result of the spread of cancer cells from the original seat of the cancer to other parts of the body, and that this spread is much hindered by the ability of the lymph nodes to catch the cancer cells and hold them. Unfortunately sooner or later some of the cells will escape beyond the lymph nodes and so spread the malignant growth throughout the body, but until this happens the cancer is confined to the region where it started, and it is during this period that complete cure by surgical means is possible. ”

“ The only chance of a radical cure consists, he says, in making a complete excision of the part; but in doing this he forbids us to secure the arteries with ligatures, as they will occasion a recurrence of the disease. The part, he says, is loaded with a thick, black, or recrementitious blood. When the cancer is ulcerated, he disapproves of cutting and burning.
Celsus describes carcinoma as an immovable and unequal tumour, attended with swelling of the veins, which are pale or livid. ”

“ We have also seen that while there has not been demonstrated any very definite and specific change in the bio-chemistry of tumors, and no specific enzymes or poison secreted by cancer cells which can communicate 104the disease, there is evidence that the disordered cells secrete a something which deranges the blood and ultimately tends to end life; for the blood in advancing cancer undergoes very radical, degenerative changes, some of which improve decidedly when a cancerous mass is removed surgically, but return with the regrowth of the tumor. ”

“ If the demand be for the red cells owing to loss from hemorrhage or any of the anaemias, the fatty marrow is rapidly replaced by cellular elements; this is mainly an active proliferation of the nucleated red cells, and gives rise to the erythroblastic type of marrow. If the white cells be required, as in local suppurating abscess, general septicaemia, acute pneumonia, &c., there is an active proliferation of the myelocytes to form the polymorpho-nuclear leukocytes, so that we have in this condition a leucoblastic transformation of the fatty marrow. ”

“ Cancer is commonest in those organs which have soonest finished their work—the reproductive organs of women; and, after these, it appears most often in that organ so much more abused than any other—the stomach.
The greatest number of cases appears at or after fifty, and therefore at that age it behoves us, not to wait and see whether we shall get it or not, but to look and see that we have not got it, for of people who survive till the age of fifty, a great many more than ten per cent. die of cancer. ”

“ Formation of Secondary Growths, or Metastases.—In addition to this spread of growth by direct extension, another characteristic of malignant tumours is a tendency to dissemination, that is, to reproduce themselves in various parts of the body far removed from the original site; so that it is not unusual to find after death that a cancer of the breast has?given rise to secondary, or metastatic, deposits in the lymphatic glands, the lungs, the ribs and other bones, the brain and the abdominal organs. ”

“ In many instances it is probably independent of any secondary infection, since it occurs in both ulcerative and non-ulcerative cases. It seems to be more common in sarcoma than in carcinoma. Very large counts are rarely noted.
[p. 161] (c) Post-hemorrhagic.—Moderate leukocytosis follows hemorrhage and disappears in a few days.
(d) Toxic.—This is a rather obscure class, which includes gout, chronic nephritis, acute yellow atrophy of the liver, ptomain poisoning, prolonged chloroform narcosis, and quinin poisoning. Leukocytosis may or may not occur in these conditions, and is not important. ”

“ What is a Cancer?
It is a hard, painful, and ulcerous Tumour, produc'd by an adult Humour, the Malignity whereof can scarce be suppress'd by any Remedies.
How many sorts of Cancers are there?
There are two kinds, viz. The Primitive and the Degenerate; the Primitive Cancer is that which comes of it self, and appears at first about the bigness of a Pea or Bean, which nevertheless doth not cease to cause an inward Pain, continual, and pricking by intervals; during this time it is call'd an Occult Cancer; but when grown bigger, and open'd, it bears the Name of an Ulcerated Cancer ”

“ I explained at the time that any attempt to excise portions of tissue for such study would at once endanger the patient and imperil the success of treatment, by giving occasion to metastases, from the opening of blood vessels and lymphatics. This matter is treated of more fully in the present lectures. It is to be remembered that the vast majority of operations for cancer are undertaken upon a purely clinical diagnosis, and it may be undeniably stated that not one half of them are confirmed subsequently by competent microscopic evidence, except, of course, in properly equipped hospitals. ”

“ We see, thus, that cancer is not primarily a surgical affection, and that the mere ablation of an offending portion of the body which has become diseased can never preclude a new portion from becoming affected, or prevent a recurrence in the same location; indeed, this often seems to be stimulated and increased by the trauma and by the deranged lymphatic and vascular circulation caused by the operation and the dissemination of actively growing cancer cells through these channels. ”

“ The nerve strain of modern life seems to be an element of importance, both through disturbance of metabolism, and by direct action on morbidly deranged cells.
23. No single remedy for cancer will probably ever be discovered, since it is conceded that there is no single cause for the disease.
24. Surgery has improved materially the statistics relating to the mortality of operative cases; but the total achievements along this line are insignificant compared with the general ultimate mortality of over 90 per cent. of those once afflicted with cancer. ”

“ The formation of the corpuscular elements of the blood must be greatly interfered with when metastases occur in the blood making organs, the lymphatic tissue, bone, marrow, and spleen, which probably occur 78more frequently than is generally recognized. It seems that the toxic secretion from a cancerous mass has a distinct action upon the blood, for after complete removal there is often observed an increase of hæmoglobin, as I have witnessed, and a high leucocytosis has disappeared after the removal of schirrus of the breast, only to return again with the recurrence of the tumor. ”