Mrs. E. H.—In April 1947, at the age of 46, this patient had a right radical mastectomy. The pathological diagnosis was adenocarcinoma, Grade III, with metastases to axillary lymph nodes. (Fig. 158) A course of post operative irradiation was administered. Menses had been interrupted 8 years before by a total hysterectomy and bilateral salpingo oophorec tomy.

Anteroposterior view of chest in Case E.H.

Fig. 159. Anteroposterior view of chest in Case E.H. at conclusion of testosterone and deep X ray therapy to spine, showing destruction of medial 1/3 of left clavicle and metastatic rib lesions.

The patient was free of symptoms until July 1948, when she began to complain of back pain and difficulty in walking. X ray examination revealed osteolytic metastatic lesions in the medial third of the left clavicle, pelvis, thoracic and lumbar vertebrae, with collapse of the ninth thoracic and third lumbar vertebrae. She was hospitalized and deep X ray therapy was applied to the thoracic and lumbar vertebral regions and the right hip, 1800 r. being delivered to each of the three fields. A total of 600 mgm. of testosterone propionate was also administered in four weeks (50 mgm. three times a week). Clinically, there was improvement and the patient was able to walk with the aid of a back brace and cane upon discharge. X ray examination on August 22, 1948, at the conclusion of this period of therapy, revealed continued spread of osteolytic lesions, involving the bodies of the lower cervical, lower thoracic and lumbar vertebrae and pelvis. Numerous lesions were observed in the left ribs and in the upper thirds of both femurs. There was further destruction of the left clavicle. (Fig. 159)

Anteroposterior view of chest in Case E.H.

Fig. 160. Anteroposterior view of chest in Case E.H. two months after stopping testosterone and X ray therapy, showing further involvement of medial 1/3 of left clavicle.

After discharge, the patient did not receive any further X ray therapy or testosterone. The clinical improvement lasted for only a short time, the back pain and difficulty in walking recurring within a few weeks. Radiographic examination at the end of October revealed further increase of the previously described lesions, with new areas of involvement. (Fig. 160)

The patient received several injections of an unknown medication at home but her condition continued to grow worse. Pain was more severe, and required increasing amounts of narcotics. The patient was confined to bed and there was evidence of increasing nerve involvement, culminating by the end of November, in paralysis of both lower limbs with loss of sensation below the level of the ninth thoracic vertebrae. There was no bladder or rectal dysfunction.

The patient came under our care in this condition on December 21, 1948. Pain was so severe that a body cast appeared indicated, but the orthopedic consultant considered the patient's condition too far advanced to warrant this. The urinary pH was alkaline.

Lateral view of thoracic spine in Case E.H.

Fig. 161. Lateral view of thoracic spine in Case E.H. at time of admission, showing extensive metastatic involvement of vertebrae with collapse of fifth and ninth vertebrae.

A hydropersulfide preparation with 0.5% sulfur was administered in doses ranging from several drops by mouth to 1 cc. twice a day intramuscularly. Sodium thiosulfate in a 10% aqueous solution was given at the same time by mouth, and after a few weeks a 4% solution administered intramuscularly was substituted and was given in increasing doses up to as much as 11 cc. every few hours. For a short period, colloidal sulfur was administered in doses of 100 mgm. orally every three hours.

During the first few weeks, with small oral doses of sulfur in oil and sodium thiosulfate, there was no evidence of improvement. 2 cc. doses of sodium thiosulfate provided definite pain relief for a short time after each injection and the gradual increase of the individual dose to 11 cc. over a twelve week period gave complete pain relief. During this time, the patient's general condition improved rapidly. Motion and sensation returned to the toes, feet and finally to the whole leg. By April, the patient was able to sit out of bed. By the end of May, she was ambulatory without requiring a brace or cane. Her only complaint was a mild facial acne that developed during the course of treatment.

Anteroposterior view of left shoulder region in Case E.H.

Fig. 162. Anteroposterior view of left shoulder region in Case E.H. four months after stopping testostercne and X ray therapy at time of admission, showing involvement of entire left clavicle and continued spread in left seventh and eighth ribs pos teriorly.

Radiographic examinations were made at the beginning of treatment and each month thereafter. At the beginning, four months after the last X ray treatment and doses of testosterone, osteolytic metastases were observed in all the vertebrae of the cervical spine and the bodies of the lower thoracic and lumbar vertebrae, with compression fractures of the third, fifth and ninth thoracic vertebrae. The entire pelvis was involved (Fig. 163) and there was destruction throughout the entire length of the left clavicle, in the left acromial process, both humeri and several ribs on the left side. (Fig. 162) Vascular markings were moderately increased in both lung fields.

Anteroposterior view of pelvis and upper 1/3 of both femurs in Case E.H

Fig. 163. Anteroposterior view of pelvis and upper 1/3 of both femurs in Case E.H. at time of admission, showing widespread osteolytic process.

Lateral view of thoracic spine in Case E.H. four months after beginning of treatment

Fig. 164. Lateral view of thoracic spine in Case E.H. four months after beginning of treatment, showing considerable bone regeneration in all vertebrae.

Comparison with previous films showed definite evidence of continued spread of the metastatic process.

Films in February showed no change, but in March, slight regressive changes were observed, especially in the left clavicle, left humerus and pelvis. During this time the urine became acid and remained so almost continuously. In April regressive changes were observed in the ribs, pelvis, femurs and left shoulder girdle. Elsewhere no further involvement was noted.

Anteroposterior view of left shoulder region in Case E.H.

Fig. 165. Anteroposterior view of left shoulder region in Case E.H. four months after beginning of therapy, showing considerable repair of left clavicular and rib lesions.

In July 1949, regressive changes were found to be continuing in all the involved bones. (Figs. 164,165,166)

At this time, all medication was discontinued and the patient returned home. In August, the patient again complained of pain in the back, right thigh and left shoulder, and had increasing trouble walking because of difficulty in moving the right leg. The urinary pH again was alkaline. Sodium thiosulfate and sulfur in oil again were administered with relief of pain and considerable improvement in the ability to walk. A few months later the patient had a stroke from which she died in a few days.

Anteroposterior view of pelvis and upper 1/3 of both femurs in Case E.H

Fig. 166. Anteroposterior view of pelvis and upper 1/3 of both femurs in Case E.H. four months after beginning of treatment, showing considerable bone repair.