Essentials of Interventional Cancer

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 Amitabh Gulati
Vinay Puttanniah
Brian M. Bruel
William S. Rosenberg
Joseph C. Hung
Editors

Essentials of Interventional
Cancer Pain Management

123
Contents

Part I Perspectives on Cancer Pain Medicine

1 Perspectives on Interventional Cancer Pain Management�������������������������������������   3

Arvider Gill and Oscar A. de Leon-Casasola
2 The Practice of Cancer Pain: A Case Series�������������������������������������������������������������   5
Sana Shaikh

Part II Cancer Pain Syndromes

3 Pathophysiology of Cancer Pain������������������������������������������������������������������������������� 13

Stephen Lawrence Thorp
4 Chemotherapy������������������������������������������������������������������������������������������������������������� 19
Karina Gritsenko and Michael Lubrano
5 Postsurgical Pain Syndromes������������������������������������������������������������������������������������� 29
Thomas J. Van de Ven and Amitabh Gulati
6 Radiation-Induced Pain Syndromes������������������������������������������������������������������������� 39
Jasmit Brar, Grant H. Chen, and Amitabh Gulati

Part III Paradigms in Cancer Pain Syndromes

7 General Pain Management Concepts����������������������������������������������������������������������� 47

Dhanalakshmi Koyyalagunta, Maureen J. Simmonds, and Diane M. Novy
8 Head and Neck Cancer Pain ������������������������������������������������������������������������������������� 55
Vinay Puttanniah and Elena V. Zininberg
9 Breast Cancer Pain: A Review of Pathology
and Interventional Techniques����������������������������������������������������������������������������������� 63
Ali Valimahomed, Jennifer Zocca, and Amitabh Gulati
10 Thoracic Cancer Pain������������������������������������������������������������������������������������������������� 85
Joseph C. Hung, Rajiv Shah, and Amitabh Gulati
11 Gastrointestinal Cancer Pain������������������������������������������������������������������������������������� 97
Daniel Pak and Joseph C. Hung
12 Genitourinary Cancer Pain Syndromes������������������������������������������������������������������� 107
Ilan Margulis and Amitabh Gulati
13 Pediatric Cancer Pain Management������������������������������������������������������������������������� 113
Stephen L. Long and Anurag K. Agrawal

ix
x Contents

14 Pain in Hematologic Malignancies ��������������������������������������������������������������������������� 123

Kanu Sharan
15 Dermatologic Cancer Pain Syndromes��������������������������������������������������������������������� 133
Katerina Svigos, Viswanath Reddy Belum, and Mario E. Lacouture

Part IV Percutaneous Pain Techniques and Anatomy

16 Ablative Techniques ��������������������������������������������������������������������������������������������������� 141

Simon Guo and Jack W. Lam
17 Sympathetic Nervous System Blocks for the Treatment of Cancer Pain��������������� 145
Nadya M. Dhanani, Wilson A. Almonte, and Mitchell P. Engle
18 Peripheral Nerve Blocks��������������������������������������������������������������������������������������������� 167
Nantthasorn Zinboonyahgoon, Christopher R. Abrecht, and Sanjeet Narang
19 Cranial Nerve Targets������������������������������������������������������������������������������������������������� 183
Jill E. Sindt
20 Vertebroplasty, Kyphoplasty, and Sacroplasty��������������������������������������������������������� 201
Dawood Sayed and Shervin Razavian
21 Treatment Considerations for Cancer Pain Syndromes����������������������������������������� 213
Devin Peck and Gendai J. Echezona

Part V Surgical Techniques and Neuromodulation

22 Intracranial Neuroablation ��������������������������������������������������������������������������������������� 225

Roy Hwang, Ashwin Viswanathan, Ahmed M. Raslan, and Erich Richter
23 Spinal Neuroablation for Cancer Pain��������������������������������������������������������������������� 231
William S. Rosenberg, Parag G. Patil, and Ahmed M. Raslan
24 Radiosurgery��������������������������������������������������������������������������������������������������������������� 235
Simon S. Lo, Tithi Biswas, Rodney J. Ellis, and Peter C. Gerszten
25 Deep Brain Stimulation and Motor Cortical Stimulation for Malignant Pain����� 241
Joshua M. Rosenow and Jonathan Miller
26 Spinal Cord Stimulation and Oncologic Pain Management����������������������������������� 247
Neel D. Mehta and Mohammad M. Piracha
27 Peripheral Nerve Stimulation for the Treatment of Cancer Pain��������������������������� 255
Jennifer A. Sweet and Nicholas M. Boulis
28 Transcutaneous Electrical Nerve Stimulation for Cancer Pain����������������������������� 261
Jeffrey Loh

Part VI Intrathecal Drug Delivery

29 Indications for Intrathecal Pump Therapy�������������������������������������������������������������� 269

Mercy A. Udoji and Helen M. Blake
30 Intrathecal Drug Delivery System Trialing for Cancer Pain Management����������� 273
Namrata Khimani and Sanjeet Narang
31 Intrathecal Pump Implantation Technique ������������������������������������������������������������� 277
Shane E. Brogan and Christina Bokat
Contents xi

32 Medications in Intrathecal Pumps ��������������������������������������������������������������������������� 287

Grant H. Chen
33 Compounding Drugs for Intrathecal Use����������������������������������������������������������������� 293
Shalini Shah

Part VII Interventional Oncology

34 Image Guidance and Planning����������������������������������������������������������������������������������� 301

Ramon Go and Jeffrey Prinsell Jr.
35 Ablative Techniques for Painful Metastasis (Radiofrequency ablation,
Microwave ablation, Cryoablation, Chemical ablation, and HIFU) ��������������������� 307
Hooman Yarmohammadi
36 Introduction to Radiation Therapy��������������������������������������������������������������������������� 319
Shayna E. Rich and Kavita V. Dharmarajan
37 Palliative Radiation Therapy������������������������������������������������������������������������������������� 329
Shayna E. Rich and Kavita V. Dharmarajan
38 External Beam Radiotherapy in the Treatment of Painful
Bone Metastases ��������������������������������������������������������������������������������������������������������� 339
Candice Johnstone, Amol J. Ghia, and Anussara Prayongrat
39 Non-opioid Intravenous Infusions for Management
of Cancer-Associated Pain����������������������������������������������������������������������������������������� 353
Yury Khelemsky and Mourad M. Shehabar

Part VIII Interventional Physiatry

40 Cancer Rehabilitation������������������������������������������������������������������������������������������������� 363

Ameet Nagpal, Jacob Fehl, Brittany Bickelhaupt, Maxim S. Eckmann,
Brian Boies, and Jon Benfield
41 Neuromuscular Medicine: Cancer Pain������������������������������������������������������������������� 375
Eric Leung
42 Cancer-Related Pelvic Pain��������������������������������������������������������������������������������������� 385
Sarah Hwang and Megan Clark
43 Exercise Therapy and Fatigue Management ����������������������������������������������������������� 395
Jack B. Fu and Arash Asher
44 Physical Therapy��������������������������������������������������������������������������������������������������������� 403
Monica Verduzco-Gutierrez, Roy Rivera Jr., and Prathap Jayaram
45 Occupational Therapy ����������������������������������������������������������������������������������������������� 417
Meilani Mapa and Jason Chen
46 Cancer Pain and Physical Modalities����������������������������������������������������������������������� 427
Joel Frontera and Amy Cao
47 Osteopathic Treatment for Cancer-­Related Pain����������������������������������������������������� 433
Ryan K. Murphy and Jonas M. Sokolof
48 Rehabilitation-Bracing as a Conservative Treatment Option��������������������������������� 443
Lisa Marie Ruppert and Michelle Yakaboski
xii Contents

Part IX Complementary and Psycho-Behavioral Therapies

49 Psychosocial Assessment and Treatment for Patients with Cancer Pain��������������� 451
Laura M. van Veldhoven and Diane M. Novy
50 Relaxation Techniques and Biofeedback for Cancer Pain Management��������������� 463
Asimina Lazaridou and Robert R. Edwards
51 Mood and Anxiety in Cancer Pain ��������������������������������������������������������������������������� 473
R. Garrett Key and William S. Breitbart
52 Acupuncture and Cancer Pain����������������������������������������������������������������������������������� 485
Yan Cui Magram and Gary E. Deng
53 Creative Therapies and Mind-Body Health Systems����������������������������������������������� 489
Veena Sankar
54 Botanical Treatments in Cancer Pain Management ����������������������������������������������� 503
Helen M. Blake
55 Integrative Therapies for Pain Modulation ������������������������������������������������������������� 507
Joan Pope and Aron Legler
Index������������������������������������������������������������������������������������������������������������������������������������� 513
Contributors

Christopher R. Abrecht, MD Department of Anesthesiology, Perioperative and Pain

Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Anurag K. Agrawal, MD Department of Hematology/Oncology, UCSF Benioff Children’s
Hospital Oakland, Oakland, CA, USA
Wilson A. Almonte, MD Victoria Pain and Rehabilitation Center, Victoria, TX, USA
Arash Asher, MD Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical
Center, Los Angeles, CA, USA
Viswanath Reddy Belum, MD Department of Medicine, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
Jon Benfield, DO South Texas Spinal Clinic, San Antonio, TX, USA
Brittany Bickelhaupt, MD University of Texas Health Science Center at San Antonio
(UTHSCSA), Department of Physical Medicine and Rehabilitation, San Antonio, TX, USA
Tithi Biswas, MD University Hospitals Seidman Cancer Center, Case Comprehensive Cancer
Center, Department of Radiation Oncology, Cleveland, OH, USA
Helen M. Blake, MD Pain and Rehabilitation Specialists of Saint Louis, LLC, St. Louis, MO,
USA
Brian Boies, MD University of Texas Health Science Center at San Antonio (UTHSCSA),
UT Medicine Pain Consultants, Department of Anesthesiology, San Antonio, TX, USA
University of Texas Health Science Center at San Antonio (UTHSCSA), Department of
Anesthesiology, San Antonio, TX, USA
Christina Bokat, MD, MPhil University of Utah, Department of Anesthesiology, Salt Lake
City, UT, USA
Nicholas M. Boulis, MD Neurosurgery, Emory University Hospital, Atlanta, GA, USA
Jasmit Brar, MD New York Presbyterian-Weill Cornell Medicine, Department of
Anesthesiology, New York, NY, USA
William S. Breitbart, MD Department of Psychiatry and Behavioral Sciences, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
Shane E. Brogan, MD, MPhil University of Utah, Department of Anesthesiology, Salt Lake
City, UT, USA
Amy Cao Baylor St. Luke’s Medical Center, Physical medicine and rehabilitation, Houston,
TX, USA
Grant H. Chen, MD Memorial Sloan Kettering Cancer Center, Department of Anesthesiology
and Critical Care Medicine, New York, NY, USA

xiii
xiv Contributors

Jason Chen, DO McGovern Medical School at UT Health, Department of Physical Medicine and
Rehabilitation, The University of Texas Health Science Center at Houston, Houston, TX, USA
Megan Clark, MD University of Kansas, Department of Physical Medicine and Rehabilitation,
Kansas City, KS, USA
Yan Cui Magram, MD New York Presbyterian Hospital-Weill Cornell Medicine, Department
of Anesthesiology, New York, NY, USA
Oscar A. de Leon-Casasola, MD The Jacobs School of Medicine and Biomedical Sciences,
Department of Anesthesiology, Buffalo, NY, USA
Division of Pain Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
Gary E. Deng, MD, PhD Memorial Sloan Kettering Cancer Center, Department of Integrative
Medicine Service, New York, NY, USA
Nadya M. Dhanani, MD Memorial Hermann Hospital/Mischer Neuroscience Institute,
Department of Pain Management/Neurosurgery, Houston, TX, USA
Kavita V. Dharmarajan, MD, MSc Icahn School of Medicine at Mount Sinai, New York,
NY, USA
Gendai J. Echezona, MD Eagle Consulting Services,White Plains, NY, USA
Maxim S. Eckmann, MD University of Texas Health Science Center at San Antonio (UTHSCSA),
UT Medicine Pain Consultants, Department of Anesthesiology, San Antonio, TX, USA
University of Texas Health Science Center at San Antonio (UTHSCSA), Department of
Anesthesiology, San Antonio, TX, USA
Robert R. Edwards, PhD Department of Anesthesiology, Perioperative, and Pain Medicine,
Brigham & Women’s Hospital and Harvard Medical School, BWH Pain Management Center,
Chestnut Hill, MA, USA
Rodney J. Ellis, MD University Hospitals Seidman Cancer Center, Case Comprehensive
Cancer Center, Department of Radiation Oncology, Cleveland, OH, USA
Mitchell P. Engle, MD, PhD Institute of Precision Pain Medicine, Corpus Christi, TX, USA
Jacob Fehl, MD Kansas City VA Medical Center, Kansas City, MO, USA
Joel Frontera, MD McGovern Medical School at The University of Texas Health Science
Center at Houston (UTHealth), Houston, TX, USA
Jack B. Fu, MD Department of Palliative Care & Rehabilitation Medicine, University of
Texas MD Anderson Cancer Center, Houston, TX, USA
R. Garrett Key, MD University of Texas at Austin Dell Medical School, Austin, TX, USA
Peter C. Gerszten, MD, MPH, FACS University Hospitals Seidman Cancer Center, Case
Comprehensive Cancer Center, Department of Radiation Oncology, Cleveland, OH, USA
Amol J. Ghia, MD University of Texas MD Anderson Cancer Center, Department of
Radiation Oncology, Houston, TX, USA
Arvider Gill, DO The Jacobs School of Medicine and Biomedical Sciences, Department of
Anesthesiology, Buffalo, NY, USA
Ramon Go, MD Pain Management, Memorial Sloan Kettering Cancer Center, New York,
NY, USA
Karina Gritsenko, MD Montefiore Medical Center – Albert Einstein College of Medicine,
Bronx, NY, USA
Amitabh Gulati, MD, FIPP Department of Anesthesiology and Critical Care, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
Contributors xv

Simon Guo, MD Northport Veterans Affairs Medical Center, Department of Anesthesia,

Northport, NY, USA
Joseph C. Hung, MD Memorial Sloan Kettering Cancer Center, Anesthesiology and Critical
Care Medicine, New York, NY, USA
Roy Hwang West Virginia University, Department of Neurosurgery, Morgantown, WV, USA
Sarah Hwang, MD Shirley Ryan AbilityLab, Chicago, IL, USA
Prathap Jayaram, MD Baylor College of Medicine, Department of Physical Medicine and
Rehabilitation, Houston, TX, USA
Candice Johnstone, MD, MPH Department of Radiation Oncology, Medical College of
Wisconsin, Milwaukee, WI, USA
Yury Khelemsky, MD Icahn School of Medicine at Mount Sinai, Department of
Anesthesiology, New York, NY, USA
Namrata Khimani, MD Department of Anesthesiology, Perioperative and Pain Medicine,
The Pain Management Center at Brigham and Women’s Hospital, Chestnut Hill, MA, USA
Dhanalakshmi Koyyalagunta, MD Department of Pain Medicine, UTMD Anderson Cancer
Center, Houston, TX, USA
Mario E. Lacouture, MD Department of Medicine, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
Jack W. Lam, MD Rex Hospital, Wake Med Cary Hospital, Duke Raleigh Hospital,
Department of Anesthesia, Raleigh, NC, USA
Asimina Lazaridou, PhD Department of Anesthesiology, Brigham & Women’s Hospital and
Harvard Medical School, BWH Pain Management Center, Chestnut Hill, MA, USA
Aron Legler, MD Memorial Sloan Kettering, Department of Anesthesiology, New York, NY, USA
Eric Leung, MD Department of Physical Medicine and Rehabilitation, Northwell Health,
Manhasset, NY, USA
Jeffrey Loh, MD, MS Queen’s Medical Center, Department of Anesthesiology & Pain
Management, Honolulu, HI, USA
Stephen L. Long, MD Department of Anesthesiology, UCSF Benioff Children’s Hospital
Oakland, Oakland, CA, USA
Simon S. Lo, MD, FACR University of Washington School of Medicine, Department of
Radiation Oncology, Seattle, WA, USA
Michael Lubrano, MD, MPH Department of Anesthesia & Perioperative Care, University of
California San Francisco (UCSF) Medical Center, San Francisco, CA, USA
Meilani Mapa, MD Memorial Rehabilitation Institute, Memorial Healthcare Systems,
Division of Physical Medicine and Rehabilitation, Hollywood, FL, USA
Ilan Margulis Department of Anesthesiology, New York-Presbyterian Hospital/Weill Cornell
Medicine, New York, NY, USA
Neel D. Mehta, MD Joan and Sanford I. Weill Cornell Medical College of Cornell University,
New York Presbyterian Hospital, Division of Pain Management, Department of Anesthesiology,
New York, NY, USA
Jonathan Miller, MD, FAANS, FACS University Hospitals Case Medical Center, Case
Western Reserve University, Cleveland, OH, USA
Ryan K. Murphy, DO Valley Medical Group, Waldwick, NJ, USA
xvi Contributors

Ameet Nagpal, MD, MS, MEd University of Texas Health Science Center at San Antonio
(UTHSCSA), UT Medicine Pain Consultants, Department of Anesthesiology, San Antonio,
TX, USA
University of Texas Health Science Center at San Antonio (UTHSCSA), Department of
Anesthesiology, San Antonio, TX, USA
Sanjeet Narang, MD Department of Anesthesiology, Perioperative and Pain Medicine, The
Pain Management Center at Brigham and Women’s Hospital, Harvard Medical School,
Chestnut Hill, MA, USA
Diane M. Novy, PhD Department of Pain Medicine, The University of Texas MD Anderson
Cancer Center, Houston, TX, USA
Daniel Pak, MD Massachusetts General Hospital, Boston, MA, USA
Parag G. Patil, MD, PhD University of Michigan Medical Center, Ann Arbor, MI, USA
Devin Peck, MD Physician, Austin Interventional Pain, Austin, TX, USA
Mohammad M. Piracha, MD Joan and Sanford I. Weill Cornell Medical College of Cornell
University, New York Presbyterian Hospital, Division of Pain Management, Department of
Anesthesiology, New York, NY, USA
Joan Pope, MSN Memorial Sloan Kettering, New York, NY, USA
Anussara Prayongrat, MD King Chulalongkorn Memorial Hospital and Chulalongkorn
University, Department of Radiation Oncology, Bangkok, Thailand
Jeffrey Prinsell Jr., MD Pain Management, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
Vinay Puttanniah, MD Memorial Sloan Kettering Cancer Center, Anesthesiology and
Critical Care Medicine, New York, NY, USA
Ahmed M. Raslan, MD Oregon Health & Science University, Department of Neurosurgery,
Portland, OR, USA
Portland VA Medical Center, Neurological Surgery, Portland, OR, USA
Shervin Razavian, MD Anesthesia Associates of Kansas City, Overland Park, KS, USA
Shayna E. Rich, MD, PhD, MA Haven Hospice, Gainesville, FL, USA
Erich Richter, MD, FAANS New Orleans Neurosurgical Associates, Marrero, LA, USA
Roy Rivera Jr., PT, PhD, DPT, CHES Crom Rehabilitation, LLC, Department of Outpatient
Sports Medicine, Houston, TX, USA
William S. Rosenberg, MD, FAANS Center for the Relief of Pain, Kansas City, MO, USA
Joshua M. Rosenow, MD Northwestern Memorial Hospital, Department of Neurosurgery,
Neurology and Physical Medicine and Rehabilitation, Chicago, IL, USA
Lisa Marie Ruppert, MD Memorial Sloan Kettering Cancer Center, New York, NY, USA
Veena Sankar, MD Austin Anesthesiology Group, Austin, TX, USA
Dawood Sayed, MD University of Kansas Medical Center, Department of Anesthesiology
and Pain Medicine, Kansas City, KS, USA
Rajiv Shah, MD Washington University School of Medicine, Saint Louis, MO, USA
Shalini Shah, MD University of California, Irvine, Department of Anesthesiology and
Perioperative Care, Irvine, CA, USA
Sana Shaikh, MD Memorial Sloan Kettering Cancer Center, New York, NY, USA
Contributors xvii

Kanu Sharan, MD MD Anderson Cancer Center at Cooper, Department of Hematology/

Oncology, Camden, NJ, USA
Mourad M. Shehabar, MD Icahn School of Medicine at Mount Sinai, Department of
Anesthesiology, New York, NY, USA
Maureen J. Simmonds, PhD, PT University of Texas, Physical Therapy Department,
San Antonio, TX, USA
Jill E. Sindt, MD University of Utah, Department of Anesthesiology, Salt Lake City, UT,
USA
Jonas M. Sokolof, DO Department of Rehabilitative Medicine, Weill College of Medicine
Cornell University, New York, NY, USA
Department of Neurology – Rehabilitation Services, Memorial Sloan-Kettering Cancer Center,
New York, NY, USA
Katerina Svigos, BA New York University School of Medicine, New York, NY, USA
Jennifer A. Sweet, MD University Hospitals Case Medical Center, Cleveland, OH, USA
Stephen Lawrence Thorp, MD Pain Medicine, Northwell Health Phelps Hospital, Sleepy
Hollow, NY, USA
Mercy A. Udoji, MD Emory University/Atlanta Veterans’ Administration, Department of
Anesthesiology, Decatur, GA, USA
Ali Valimahomed, MD Department of Physical Medicine and Rehabilitation, New York-
Presbyterian Hospital, Weill Cornell Medical College/Columbia University Vagelos College of
Physicians and Surgeons, New York, NY, USA
Laura M. van Veldhoven, PhD, MPH Department of Physical Medicine and Rehabilitation,
Baylor College of Medicine, Houston, TX, USA
Thomas J. Van de Ven, MD, PhD Duke University Medical Center and Durham VAMC,
Department of Anesthesiology, Durham, NC, USA
Monica Verduzco-Gutierrez, MD Department of Physical Medicine and Rehabilitation,
University of Texas Health Science Center, Houston, TX, USA
Ashwin Viswanathan Baylor College of Medicine, Department of Neurosurgery, Houston,
TX, USA
Michelle Yakaboski, CPO Certified Prosthetist Orthotist at Boston Orthotics and Prosthetics,
Stony Brook, NY, USA
Hooman Yarmohammadi, MD Certified Prosthetist Orthotist at Boston Orthotics and
Prosthetics, Stony Brook, NY, USA
Nantthasorn Zinboonyahgoon, MD Department of Anesthesiology, Faculty of Medicine
Siriraj Hospital, Mahidol University, Bangkok, Thailand
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
Elena V. Zininberg, MD Weill Cornell School of Medicine, Department of Anesthesiology,
New York, NY, USA
Department of Anesthesiology/Pain Management, Memorial Sloan Kettering, New York,
NY, USA
Jennifer Zocca, MD Department of Anesthesiology, New York-Presbyterian Hospital, Weill
Cornell Medical College, New York, NY, USA
 Part I
Perspectives on Cancer Pain Medicine
 Perspectives on Interventional Cancer
Pain Management
Arvider Gill and Oscar A. de Leon-Casasola
As of January 2012, approximately 13.7 million Americans
with a history of cancer were alive [1]. It is unclear how
many of these individuals were cancer-free and how many
had evidence of cancer and may have been undergoing treat-
ment. Regardless, the burden of disease is significant; about
1,665,540 new cancer cases, not including cancer in situ, are
expected to be diagnosed in 2014 [1]. If 30–50% of individu-
als with advanced cancer experience significant pain, then
one can understand the high prevalence of pain affecting this
population. Moreover, the 5-year relative survival rate for all
cancers diagnosed between 2003 and 2009 is 68%, up from
49% in 1975–1977 [1]. These numbers explain the high
number of patients experiencing pain due to their cancer
treatments, including chemotherapy-induced peripheral neu-
ropathy, postradiation visceral and neuropathic pain, and
postsurgical pain syndromes. These survivors have increased
the need for resources to treat these patients at cancer cen-
ters, as they have complex pain syndromes that are not man-
aged by community physicians.
Despite advances in the understanding of the neurobiol-
ogy of pain in cancer, the translation of this information to
multimodal pharmacologic analgesic therapy and the
advent of new interventional techniques for the manage-
ment of cancer pain have not shown a dramatic reduction in
the prevalence of patients experiencing cancer pain.
Recently, a group in the Netherlands reported that 55% of
the 1429 respondents with a diagnosis of cancer had expe-
rienced moderate to severe pain in the week prior to the
A. Gill
The Jacobs School of Medicine and Biomedical Sciences,
Department of Anesthesiology, Buffalo, NY, USA
O. A. de Leon-Casasola (*)
The Jacobs School of Medicine and Biomedical Sciences,
Department of Anesthesiology, Buffalo, NY, USA
Division of Pain Medicine, Roswell Park Cancer Institute,
Buffalo, NY, USA
e-mail: Oscar.deleon@roswellpark.org
© Springer Nature Switzerland AG 2019
A. Gulati et al. (eds.), Essentials of Interventional Cancer Pain Management, https://doi.org/10.1007/978-3-319-99684-4_1
1
survey and that 42% of patients were experiencing pain
despite receiving pharmacological treatment for it [2]. In
the United States, 3,123 ambulatory patients with breast,
prostate, colorectal, or lung cancer were evaluated for pain
at their first visit and then 4–5 weeks later. Of those patients,
67% had pain and ongoing pharmacological treatment with
opioids at the first visit. However, 33% did not have ade-
quate pain control at that time despite their treatment with
opioids [3]. At the follow-­up visit, though they continued
treatment with opioids, there was no reduction in the num-
ber of patients experiencing inadequate pain control [3].
This study also showed that the prevalence of pain due to
solid tumors has not changed in the United States in more
than 20 years, despite the wide availability and increased
consumption of opioids [3]. In contrast, a randomized clini-
cal trial comparing intrathecal therapy (IT) to comprehen-
sive medical management (CMM) in the treatment of
refractory cancer pain showed that once the patients were
enrolled into the study, and then treated by a pain specialist,
there was a further 39% pain reduction in patients allocated
to the CMM group versus a 51% in those receiving IT ther-
apy [4]. The difference was not statistically significant
illustrating the power of pharmacological therapy in the
hands of pain specialists.
These findings suggest that the involvement of a pain spe-
cialist may have a significant impact in the quality of pain
control experienced by cancer patients. This difference may
be the result of the implementation of multimodal therapy
with topical analgesics [5], judicious opioid use [6], anticon-
vulsants with modulating capabilities of the voltage-gated
calcium channel [7], tricyclic antidepressants [7], and titra-
tion to doses associated with therapeutic effects [8]. The
importance of adequate pain management in cancer patients
needs to be underscored because there is evidence in the
oncology literature that survival rates are proportionally
related to symptom control and that pain management con-
tributes to better psychosocial functioning and quality of life
[9]. Because of the interactions of psychosocial issues and
3
4 A. Gill and O. A. de Leon-Casasola
pain, care for these patients is best provided in a multidisci-
plinary environment where psychological support includes
emotional support, coping skills training, and cognitive
behavioral therapy [10].
As noted, evaluation of pain is critically important in the
oncology patient. Pain intensity must be quantified, and quality
must be characterized by the patient (whenever possible based
on patient communication capacity). The brief pain inventory
is an appropriate tool for this purpose [11], while the short
form McGill Pain Questionnaire may be used in cancer patient
to evaluate the multidimensionality of pain [12]. A comprehen-
sive pain assessment should be performed if new pain is pres-
ent and regularly performed for persisting pain. Moreover, the
quality of pain must be evaluated to determine if there is a
neuropathic pain component. There are several neuropathic
pain scales that may be implemented for this purpose, includ-
ing the Douleur Neuropathique (DN4) [13] and the Leeds
assessment of neuropathic symptoms and signs (LANSS) [14],
which are easy to use, and may be applied in a short period of
time. The patient impression of adequate pain relief and the
healthcare provider assessment of adequacy of function, and
any special issues for the patient relevant to pain treatment, is
also necessary to have a complete evaluation of the success of
therapy. Because patients with cancer pain will likely need opi-
oid therapy, it is also important to evaluate the patient for the
risk of abuse and diversion. Several tools have been created for
this purpose and can be easily implemented [15, 16].
Pharmacological pain therapy is very successful in cancer
pain [6, 17]. However, invasive techniques are sometimes
needed because patients cannot tolerate pharmacologic titra-
tion to therapeutic levels or because inadequate analgesia is
achieved despite maximum doses of these agents. In these
individuals, there are several options. These include neuro-
lytic blocks of the sympathetic axis for those patients with a
visceral pain component [18, 19], intrathecal therapy for both
somatic and neuropathic pain components [20–22], periph-
eral and spinal cord stimulation [23], and other interventional
procedures performed in the non-cancer population, as non-
cancer-related pain may also occur in this population.
In summary, the use of pharmacological multimodal ther-
apy and interventional procedures may result in successful
pain control in the great majority of patients afflicted by
cancer-related pain when implemented by practitioners well
versed in the use of these alternative therapies.
References
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American Cancer Society; 2014.
2. van den Bueuken-van Everdingen MHJ, de Rijke JM, Kessels AG,
Schouten HC, van Kleef M, Parjin J. High prevalence of pain in
patients with cancer in a large population-based study in the The
Netherlands. Pain. 2007;132:312–20.
3. Fisch MJ, Lee J-W, Weiss M, Wagner LI, Chang VT, Cella V,
Manola JB, Minasian LM, McCaskill-Stevens W, Mendoza TR,
Cleeland CS. Prospective, observational study of pain and analge-
sic prescribing in medical oncology outpatient with breast, colorec-
tal, lung, or prostate cancer. J Clin Oncol. 2012;30:1980–91.
4. Smith TJ, Staats PS, Deer T, Stearns LJ, Rauck RL, Boortz-Marx RL,
Buchser E, Catala E, Bryce DA, Coyne PJ, Pool GE. Randomized
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comprehensive medical management for refractory cancer pain:
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2002;20:4040–9.
5. de Leon-Casasola OA. Multimodal approaches to the management
of neuropathic pain: the role of topical analgesia. J Pain and Symp
Manag. 2007;33:356–64.
6. de Leon-Casasola OA. Current developments in opioid therapy
for the management of cancer pain. Clin J Pain. 2008;24(Suppl
10):S3–7.
7. O’Connor AB, Dworkin RH. Treatment of neuropathic pain: an
overview of recent guidelines. Am J Med. 2009;122:S22–32.
8. de Leon-Casasola OA. Multimodal, multiclass, multidisciplinary
therapy: the key to better analgesia in the 21st century? Clin J Pain.
2010;26(Suppl 10):S1–2.
9. Temel JS, Greer JA, Muzikansky A. Early palliative care for
patients with metastatic non-small-cell lung cancer. N Engl J Med.
2010;363:733–42.
10. Morley S, Eccleston C, Williams A. Systematic review and meta-­
analysis of randomized controlled trials of cognitive behavior
therapy and behavior therapy for chronic pain in adults, excluding
headache. Pain. 1999;80:1–13.
11. Cleeland CS, Ryan KM. Pain assessment: global use of the brief
pain inventory. Ann Acad Med Singapore. 1994;23:129–38.
12. Gauthier LR, Young A, Dworkin RH, Rodin G, Zimmermann
C, Warr D, Librach SL, Moore M, Sheperd FA, Riddell RP,
Macpherson A, Melzack R, Gagliese L. Validation of the short-­
form Mc Gill pain questionnaire-1 in younger and older people
with cancer pain. J Pain. 2014;15:756–70.
13. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle
J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A, Jafari-­
Schluep H, Lanteri-Minet M, Laurent B, Mick G, Serrie A, Valade
D, Vicaut E. Comparison of pain syndromes associated with ner-
vous or somatic lesions and development of a new neuropathic pain
diagnostic questionnaire (DN4). Pain. 2005;114:29–36.
14. Bennett M. The LANSS pain scale: the Leeds assessment of neuro-
pathic symptoms and signs. Pain. 2001;92:147–57.
15. Moore TM, Jones T, Browder JH, Daffron S, Passik SD. A compar-
ison of common screening methods for predicting aberrant drug-­
related behavior among patients receiving opioids for chronic pain
management. Pain Med. 2009;10:1426–33.
16. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-­
treated patients: preliminary validation of the opioid risk tool. Pain
Med. 2005;6:432–42.
17. de Leon-Casasola OA. Implementing therapy with opioids in can-
cer pain. Oncol Nurs Forum. 2008;35(6):S1–6.
18. Wong GY, Schroeder DR, Carns PE, Wilson JI, Martin DP, Kinney
MO, Mantilla CB, Warner DO. Effect of neurolytic celiac plexus
block on pain relief, quality of life, and survival in patients with
unresectable pancreatic cancer. A randomized controlled trial.
JAMA. 2004;291:1092–9.
19. de Leon-Casasola OA, Kent E, Lema MJ. Neurolytic superior
hypogastric plexus block for chronic pelvic pain associated with
cancer. Pain. 1993;54:145–51.
20. Lozano J, de Leon-Casasola OA. Indications for intrathecal therapy
in cancer patients. Tech Reg Anesth Pain Manag. 2011;15:147–9.
21. de Leon-Casasola OA. Implementing and managing intrathecal
pumps. Tech Reg Anesth Pain Manag. 2011;15:155–7.
22. Sparlin J, de Leon-Casasola OA. Intrathecal pump implantation
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2009;38:S28–38.
 The Practice of Cancer Pain:
A Case Series
Sana Shaikh
Introduction
Surviving cancer is just the beginning. Often the struggle for
many patients is thriving after treatment which may be lim-
ited by pain. While strategies to treat pain in the chronic pain
population exist, implementing pharmacologic and interven-
tional therapies for the cancer pain patient may be challeng-
ing. The following case series illustrate a framework that
chronic pain physicians may use to treat cancer pain
syndromes.
The clinical practice of pain management can vary from
one practice to another based on patient population and
referrals. In community-based practices, practitioners may
have a consistent population base with similar anatomy and
pathophysiology. A distinct challenge to the practice of can-
cer pain medicine is that each patient’s tumor pathology and
metastatic disease leads to evolving sources of pain. It is
important to consistently reevaluate imaging as the primary
and secondary diseases result in changing pain syndromes.
Choosing interventions is often balanced with oncologic
treatment protocols and life expectancy.
Case 1: Oncologic Diagnosis in the Community
Setting The incidence of cancer is 454.8 cases per 100,000
men and women per year (based on 2008–2012 cases) [1].
The epidemiology of cancer pain among diagnosed cases of
cancer is variable depending on the source. A systematic
review of 52 articles showed that pain was prevalent in 64%
of patients with metastatic or advanced-stage disease, 59%
in patients on anticancer treatment, and 33% in patients after
curative treatment [2]. Another study estimated the preva-
lence of pain in cancer at 25% for those newly diagnosed,
33% for those undergoing active treatment, and greater than
75% for those with advanced-stage disease[3, 4]. Due to the
S. Shaikh (*)
Memorial Sloan Kettering Cancer Center, New York, NY, USA
e-mail: shaikhs@mskcc.org
© Springer Nature Switzerland AG 2019
A. Gulati et al. (eds.), Essentials of Interventional Cancer Pain Management, https://doi.org/10.1007/978-3-319-99684-4_2
2
high prevalence of pain as a symptom in cancer patients, it is
important to consider an underlying oncologic process in the
differential diagnosis when evaluating the initial presenta-
tion of pain.
Case 1: A 75-year-old female with a distant history of
non-small cell lung cancer presents with right shoulder pain.
The pain in the right-sided shoulder is a constant, sharp pain
with radiation to the lateral aspect of the deltoid, elbow, and
anterior chest wall over the right pectoralis muscle. She
denies any numbness or tingling in the arm. Upon initial pre-
sentation of pain, the patient was evaluated at a community-­
based pain practice where she was given a prescription for
physical therapy for the right shoulder and an intraarticular
steroid injection.
The patient noted that physical therapy exacerbated her
shoulder pain and that the injection resulted in minimal
improvement of her symptoms. Multiple opioid regimens
were tried with dose-limiting nausea noted and a lack of
adequate pain relief achieved. Despite the addition of ste-
roids, nerve pain-modulating medications, and muscle relax-
ants, the pain progressively worsened at which time she
presented to the hospital with severe pain and limited ability
to move the right shoulder.
CT examination of the right shoulder revealed a lytic
lesion in the glenoid process of the right scapula along with
a complete supraspinatus tear (Fig. 2.1). A PET scan showed
a large lytic lesion within the right coracoid process extend-
ing into the glenoid process. She was started on a regimen of
steroids and radiation therapy to the right glenoid process.
After 2 weeks of radiation with minimal improvement in
symptoms, both the interventional pain service and orthope-
dic surgery were consulted for possible interventions to
improve patient’s shoulder pain.
Given her the anatomy and location of her pathology, the
patient would unlikely benefit from an additional intraar-
ticular shoulder joint injection. A consultation and discus-
sion with orthopedic surgery led to a recommendation of
5
6 S. Shaikh
Fig. 2.1 CT scan of the right upper extremity is demonstrating a lytic
metastasis in the superior glenoid (arrows) with new cortical break-
through and an extraosseous soft tissue component and new probable
nondisplaced, pathologic fracture
surgical resection of the coracoid and scapula fracture
along with rotator cuff tendon repairs. After pain manage-
ment, anesthesia, and surgical discussion, it was decided to
proceed with the surgery with preoperative nerve blocks to
help with postoperative pain control and rehabilitation.
Ultrasound guidance was used to target right cervical C5
and C6 for neural blockade in combination with the PECSII
nerve block. Perioperatively, the patient was noted to
have excellent pain relief with regional analgesia lending
to an overall perceived decrease in oral opioid regimen
requirements.
Patients undergoing orthopedic surgery for tumor resec-
tion often have anatomical considerations unique to their
tumor location. Surgical incisions and planning can often be
unpredictable and cross multiple dermatomes in comparison
with orthopedic surgery for nonmalignant pain. Careful
planning between the acute pain specialist, anesthesiologist,
and surgical teams is important to ensure adequate perioper-
ative pain relief.
Case 2: Symptom Management in Oncologic Pain
Treatment A systematic review of palliative symptoms in
cancer patients showed that their most prevalent symptoms
were fatigue, excretory symptoms, urinary incontinence,
asthenia, pain, constipation, and anxiety which occurred in at
least 50% of patients [5]. In a comparison between palliative
care in cancer and non-cancer geriatric patients, cancer
patients were found to have more pain, digestive symptoms,
psychological symptoms, and fatigue than non-cancer
patients. The study also found that the prevalence of diges-
tive symptoms, pain, and psychological symptoms was
higher in younger and in cancer patients than in the elderly
and the non-cancer patients [6]. A systematic review demon-
strated that home, hospital, and inpatient specialist palliative
care significantly improved patient outcomes in the domains
of pain and symptom control, anxiety, and reduced hospital
admissions [7]. Overall the treatment of palliative and pain
symptoms is crucial to the quality of life patients experience
as part of their cancer treatment.
Case 2: A 57-year-old male with metastatic colon cancer
involving the liver and lungs presents with intractable hic-
cups. His hiccups started after a CT scan and have occurred
every few minutes consistently with some periods of pause
not lasting longer than 20 min. As an outpatient, his oncolo-
gist tried a regimen of baclofen twice a day dosing with no
change in symptoms. He was also given a single dose of flu-
conazole to empirically treat esophageal candidiasis. As part
of the workup for this patient’s new onset of hiccups, the
patient had reimaging of the body including CT of the chest,
abdomen, and pelvis (Fig. 2.2). This imaging showed an
increase in size and number of multiple bilateral pulmonary
metastases and persistent splenomegaly, with portal venous
hypertension. It was suspected that diaphragmatic irritation
secondary to pulmonary metastatic disease was the likely eti-
ology of the patient’s persistent hiccups.
A trial of bilateral sphenopalatine ganglion blocks was
performed which resulted in only a 20 min resolution of the
hiccups. A trial of gabapentin 300 milligrams daily was initi-
ated and titrated to three times a day dosing along with a
regimen of oral viscous lidocaine to be swallowed instead of
rinsed three times a day. The patient had complete resolution
of hiccups after therapeutic titration of oral viscous lidocaine
and Neurontin at three times a day. The patient was dis-
charged on maintenance gabapentin therapy and oral viscous
lidocaine on an as-needed basis.
Fig. 2.2 CT of the chest, abdomen, and pelvis with contrast showed
slightly increased size of bilateral pulmonary metastases in the right
upper and lower lobes. The picture above showed the right peri-hilar
mass increased marked narrowing of the right upper lobe bronchus
(arrows)
2 The Practice of Cancer Pain: A Case Series
Localized treatments for pain including directed topical
treatments can often be helpful to treat novel causes of pain.
Case 3: Changing Pain States in Oncologic Patients The
symptoms of cancer often change over time, and there is a
need for practitioners to have a low threshold for reevalua-
tion of the underlying disease process. New symptoms can
manifest from treatment or from progression of cancer, either
locally or to distant sites. Diagnostic workup of these possi-
bilities is important in determining the treatment plan.
Collaboration between interventional pain and other service
may offer patients a wide variety of options to treat different
pain and non-pain symptoms during cancer treatment.
Ultimately, it is most important to consider a wide array of
therapies to optimize symptom manage and quality of life.
Case 3: A 41-year-old male with multifocal peripheral
schwannoma involving the pleura and liver presents with
right-sided chest wall pain. Interventional radiology recom-
mended cryoablation of this lesion on the anterior aspect of
the seventh rib. The patient was also referred for consultation
with the pain service for possible interventional options for
pain relief.
On initial assessment, patient noted pain as a sharp, tin-
gling, and burning in the right upper quadrant of the abdo-
men. Despite the use of opioids, the patient found the pain to
cause significant daily disability. Upon physical exam, there
was tenderness to palpation across the right seventh and
eighth rib in an anterolateral location This correlated with a
seventh rib schwannoma (Fig. 2.3). A right-sided intercostal
nerve block of the seventh and eighth ribs under ultrasound
guidance was performed.
The patient’s noted significant improvement from base-
line and that relief lasted for 11 weeks. At that time, pain
Fig. 2.3 CT of the chest and abdomen with contrast showing right-­
sided chest wall mass responsible for patient’s first onset of chest wall the abdomen and pelvis which showed enlarged perirectal
pain (arrows)
7
returned with the same presentation and severity. Given the
positive response from first procedure, the intercostal nerve
blocks were repeated; however the patient had minimal relief
from this procedure. Given this response, imaging with an
MRI of the thoracolumbar spine was repeated to evaluate for
extension of disease into the spinal cord. MRI of the spine
revealed paraspinal masses abutting exiting nerve roots at the
right T7–T8 level. A thoracic epidural was performed with
significant relief of the patient’s pain. Patient’s pain relief
lasted for 6 weeks with significant progression of the original
disease. Due to the rate of disease growth, we planned for
intrathecal pump placement to treat the neuraxial source of
the pain.
Though various nerve blocks can make sense clinically
based on the history and physical exam, it is often necessary
to correlate these findings with relevant and up-to-date imag-
ing in order to optimize efficacy and safety of a planned
intervention. It’s important to consider the possibility that an
initial intervention that was helpful may not be possible
given changes in anatomy related to progression of disease.
It is crucial to always reassess patients given the aggressive
nature of some of the baseline etiologies.
Case 4 and 5: Considerations for Intrathecal Drug
Delivery in the Oncologic Population The goal of inter-
ventional pain physician is to consider intervening in some-
one’s pain outcome as early as possible to treat a patient’s
pain and improve their quality of life and function. The intra-
thecal delivery of opioids and other adjuvant medications is
an effective way to treat refractory cancer pain while mini-
mizing systemic side effects and allowing for a greater abil-
ity to address increased pain medication requirements. A
randomized clinical trial of implantable drug systems showed
better clinical pain relief, less systemic side effects, and a
tendency toward increased survival in the treatment of can-
cer pain [8].
The following two cases describe clinical scenarios where
directed drug delivery via an intrathecal pump would be indi-
cated and how the progression of disease ultimately was the
reason to proceed or the reason to not proceed with an intra-
thecal pump placement. Intrathecal drug delivery is an espe-
cially useful method to very quickly adjust and meet
increasing opioid requirements while minimizing side
effects.
Case 4: A 35-year-old woman who was recently diag-
nosed with adenocarcinoma of the rectum in the setting of
Crohn’s disease presents for consultation with the interven-
tional pain team 6 months after being diagnosed. The
patient’s pain first started with increasing perineal discom-
fort and pain. She underwent imaging studies with MRI of
lymph nodes and three irregular hypodense masses in the
8 S. Shaikh

liver which were suspicious for metastatic disease. Liver

a
biopsy would confirm metastatic disease and rectal cancer.
Further imaging showed perirectal nodal disease and distant
mets to the liver, pleura, left adrenal, and bone.
The patient’s perirectal pain progressed to include saddle
anesthesia, with pain in the right buttock radiating around
laterally into the right groin and intermittent right first toe
paresthesia. Additional workup was consistent with exten-
sive disease from T12 through the sacrum, an L5 fracture,
left foraminal narrowing due to metastasis at L4–L5 and L5–
S1, and presacral extraosseous disease with right S2–S3
sacral nerve root impingement (Fig. 2.4a and b). She denies
bowel or bladder incontinence and noted no weakness in the
lower extremities. Interventional radiology and the pain ser-
vice were consulted for on input on symptomatic treatment
of the pain in conjunction with ongoing chemotherapy.
Radiation therapy to the sacral spine was started along with
an oral steroid regimen.
b
The patient and pain practitioner’s initial goal was to alle-
viate as much of the patient’s perineal paresthesias and radic-
ular pain as possible. Review of the MRI showed no disease
at the sacral hiatus, and a caudal epidural steroid injection
was planned. The patient’s INR was elevated likely due to
hepatic involvement and was treated with vitamin K. Once
the coagulopathy improved, a caudal epidural steroid injec-
tion was performed with moderate relief of radicular pain.
She continued to have midline sacral pain. Directed drug
delivery via an intrathecal pump was discussed given the fast
progression of the disease after completion of radiation ther-
apy. Unfortunately, the patient’s disease would continue to
progress aggressively and left her with a limited prognosis
affecting her risk and benefit profile for intrathecal pump
placement. The benefits of the procedure did not outweigh
the risks and costs for placement of an intrathecal pump.
Further goals of care were discussed with the patient, and a
plan for hospice initiation was determined. The patient’s
pain was managed with hydromorphone PCA.
Patient’s may often have pain that is amenable to directed
drug delivery via intrathecal pump; however it is important
to reconcile the patient’s wishes and beliefs regarding pallia-
tion with the risks and benefits of the procedure. An intrathe-
cal pump placement can improve patient’s ability to be
functional, and often pain is a short-term setback before the
benefits are achieved.
Case 5: A 36-year-old male with a history of sacral spin- Fig. 2.4 (a) Left MRI sacrum showing bilateral sacral metastases have
increased with bilateral presacral extraosseous disease. The right sacral
dle cell sarcoma metastatic to the pelvis presented to the
ala with metastasis infiltrates into the S2 and to a greater extent the S3
inpatient pain service after having had a left-sided hind-quar- neural foramina (arrows). (b) Right MRI lumbar spine consistent with
ter amputation (Fig. 2.5). The consultation is called for osseous metastases involving almost every level throughout the cervi-
acutely worsened pain in the left groin and pelvis on an inpa- cal, thoracic, and lumbar spine (arrows at L1, L2, and L5 vertebral dis-
ease with epidural extension at L5)
tient basis. An epidural catheter had been placed periopera-
tively for acute pain control, but a plan for intrathecal drug
delivery had simultaneously been discussed with the patient. tion can often be considered when considering the efficacy
The epidural was dosed with a combination of hydromor- of neuraxial medicine prior to intrathecal pump placement.
phone and bupivacaine solution. An epidural trial of medica- The patient noted improved pain control and side effect pro-
2 The Practice of Cancer Pain: A Case Series 9

and adjust the therapeutic plan as patients’ underlying

pathology, treatments, and goals of care change. Most impor-
tant is having a low threshold to consider that an initial
underlying pathology has changed and may require new
diagnostics or a change in management. Ultimately the goal
is optimal pain relief and to give patients a chance to enhance
their quality of life and functionality. Each patient has per-
sonal goals, and it is these benchmarks that should guide
therapy. Each patient’s case provides an opportunity for
reflection and reminds pain practitioners to learn, advance,
and develop algorithms to best treat each patient.

References
Fig. 2.5 CT of the chest, abdomen, and pelvis shows necrotic left pel-
vic mass centered at the left iliopsoas muscle and extending into the
peritoneum (arrows)
file from decrease in systemic opioid treatment. An intrathe-
cal pump was placed without any side effects or complications,
and the patient returned for subsequent outpatient visits and
for adjustment of dose over the next few months. Ultimately
the cancer progressed, and various combinations and doses
of intrathecal medications were titrated to alleviate the pain.
A retrospective case study of 46 cancer patients who had
an epidural trial discussed how to use a patient’s pre-pump
systemic opioid requirements to calculate an appropriate
intrathecal dose without having to do an epidural trial [8].
There are several ways to trial a patient for neuraxial directed
drug delivery, but epidural trial can be a reasonable option
for patients who are in the hospital.
Conclusion
This chapter highlights several different cases that can repre-
sent challenges to interventional pain physicians when treat-
ing cancer patients. It is crucial to continuously challenge
1. NIH: National Cancer Institute. Cancer statistics. https://www.can-
cer.gov/about-cancer/understanding/statistics
2. Van den Beuken-van Everdingen MH, de Rijke JM, Kessels AG,
et al. Prevalence of pain in patients with cancer: a systematic review
of the past 40 years. Ann Oncol. 2007;18(9):1437–49.
3. American Pain Society (APS). Principles of analgesic use in the
treatment of acute pain and cancer pain. 6th ed. Glenview: American
Pain Society; 2008.
4. National Comprehensive Cancer Network. Clinical practice guide-
lines in oncology for adult cancer pain. V. 1.2010. Fort Washington:
National Comprehensive Cancer Network. 2010. Available at:
www.nccn.org. Accessed 1 Nov 2010.
5. Van Lancker A, Velghe A, Van Hecke A, Verbrugghe M, Van Den
Noortgate N, Grypdonck M, Verhaeghe S, Bekkering G, Beeckman
D. Prevalence of symptoms in older cancer patients receiv-
ing palliative care: a systematic review and meta-analysis. J Pain
Symptom Manag. 2014;47(1):90–104. https://doi.org/10.1016/j.
jpainsymman.2013.02.016.
6. Borgsteede SD, et al. Symptoms in patients receiving palliative
care: a study on patient-physician encounters in general practice.
Palliat Med. 2007;21:417–23.
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lies? Cancer J. 2010;16(5):423–35. https://doi.org/10.1097/
PPO.0b013e3181f684e5.
8. Malhotra VT, Root J, Kesselbrenner J, Njoku I, Cubert K, Gulati A,
Puttanniah V, Bilsky M, Kaplitt M. Intrathecal pain pump infusions
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axial trial. Anesth Analg. 2013;116(6):1364–70.
 Part II
Cancer Pain Syndromes
 Pathophysiology of Cancer Pain
Stephen Lawrence Thorp
Introduction
The International Association for the Study of Pain defines
pain as “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage” [1]. Pain is prevalent
among patients with cancer, with a systematic review finding
pain prevalence to be 66.4% in advanced metastatic or termi-
nal disease, 55% during anticancer treatment, 39.3% after
curative treatment, and moderate to severe pain being
reported in 38.0% of all patients [2]. Adequate control of
pain can improve patient’s quality of life through improved
mood, functional status, and rest, among other things. Pain
may even be related to survival [3]. Cancer-related pain is
unique and may be related to the anatomic location of the
tumor, pathophysiology of the tumor, or treatment of the
tumor. Similarly, the origin of the pain itself can be somatic,
visceral, neuropathic, or mixed in nature. Given the com-
plexity of cancer pain and its multiple etiologies, it is critical
to assess the pathophysiology of the cancer and its role in
creating a pain syndrome.
Anatomic Location of Tumors
Pathophysiology of Bone Tumor Pain
The location of a tumor is often the direct cause of significant
pain for patients. As an example, tumors in the bone are one
of the most common sources of pain in patients with cancer.
There are multiple types of primary benign and malignant
bone tumors, and metastasis to bone is common [4]. When
tumors metastasize to the bone, the route is most commonly
hematogenous but can also be due to contiguous spread or
S. L. Thorp (*)
Pain Medicine, Northwell Health Phelps Hospital,
Sleepy Hollow, NY, USA
e-mail: sthorp@northwell.edu
© Springer Nature Switzerland AG 2019
A. Gulati et al. (eds.), Essentials of Interventional Cancer Pain Management, https://doi.org/10.1007/978-3-319-99684-4_3
3
via lymphatics. The vertebrate is the most common site of
metastasis; however the pelvis, ribs, femur, and skull are also
common sites. Patients typically present with well-localized
pain that worsens with weight bearing and activity and is
tender to palpation on physical examination.
The etiology of bone pain is complex and not fully
understood [5]. The periosteum and marrow cavity are both
innervated by peripheral nociceptors capable of causing
pain. In animal studies, it has been shown that sensory and
sympathetic neurons innervate the bone, with the perios-
teum having the densest innervation followed by the bone
marrow [6]. The sensory fibers that innervate the bone dif-
fer from more well-characterized afferents that innervate
the skin. Bone is innervated primarily by A-delta fibers, and
there is very little innervation by either C-fibers or A-β
fibers [7]. Sharp nociceptive bone pain is likely transmitted
by the A-δ fibers, and the dull ache is transmitted from the
C-fibers that become sensitized. Bone pain likely has a neu-
ropathic component as well, as invading tumor cells injure
sensory fibers [8].
When bone is invaded by cancer cells, a release of inflam-
matory mediators such as prostaglandin E2 (PGE2) sensitizes
the peripheral nociceptors. This mechanism underlies the
role for nonsteroidal anti-inflammatory (NSAIDS) agents in
treating bone pain. Metastasis and primary tumors can be
lytic, due to increased osteoclastic activity, or sclerotic, due
to increased osteoblastic activity, both of which induce
mechanical instability in the bone [9]. The instability in the
bone may eventually manifest as a vertebral compression
fractures (VCF) if the tumor is located in the vertebral body.
Fractures localized within the vertebral body may be treated
with vertebral augmentation techniques such as kyphoplasty;
however, more severe fractures resulting in neurological dys-
function and severe pain may require surgical stabilization.
13
14
Etiologies of Neuropathic Pain
Accordingly, tumor location in close proximity to neural
structures can lead to neurological impairment and neuro-
pathic pain. Neoplastic plexopathy represents a severe and dif-
ficult to treat form of cancer pain. Neoplastic plexopathy arises
when a tumor progresses to involve one of the main plexuses;
the cervical, brachial, or lumbosacral plexus. Treatment for
tumor-induced plexopathies may involve surgical or radiation
therapy, in addition to neuropathic pain medications.
The cervical plexus contains contributions from the C1,
C2, C3, and C4 spinal nerves and provides innervation for
the muscles of the neck as well as the prevertebral muscles.
Impingement upon this plexus by tumor can result in cervi-
cal plexopathy, which typically presents with pain in the
neck, shoulder, or throat. Weakness in the shoulder is related
to weakness in the trapezius and sternocleidomastoid mus-
cles, which are innervated by the spinal accessory nerve. The
patient may also have shortness of breath, particularly if
there is underlying pulmonary pathology, due to involvement
of the phrenic nerve and hemidiaphragmatic paralysis.
Cervical plexopathy is most commonly associated with head
and neck tumors and lymphomas but may also be due to lung
and breast cancers [10]. The cervical plexus can be blocked
superficially resulting in cutaneous analgesia, or by anesthe-
tizing the C2, C3, and C4 spinal nerves as they exit their
respective cervical foramina, or the deep cervical plexus.
Far more common than tumors impacting the cervical
plexus are tumors compressing the brachial plexus. The bra-
chial plexus is composed of the ventral rami of C5–T1 in
most individuals, with occasional contributions from C4 and
T2 spinal nerves. The nerve roots exit the foramina and travel
anterolateral between the anterior and middle scalene mus-
cles, where they combine to form superior, middle, and inte-
rior trunks. At approximately the level of the first rib, these
trunks again divide into an anterior and posterior division,
which then form the lateral, medial, and posterior cords, so-­
named for their relation to the axillary artery. The three cords
then divide into the peripheral nerves which supply innerva-
tion to the upper extremities.
Brachial plexopathy is most commonly associated with
lung and breast cancer. Superior sulcus, or Pancoast, tumors
are located at the apex of the lung and may impinge upon the
brachial plexus. The clinical presentation of the plexopathy is
related to where the plexus is impacted. The most commonly
affected portion of the brachial plexus is the lower roots, and
patients often present with radicular pain and radiculopathies
in an ulnar nerve distribution. When head and neck neoplasms
impact the brachial plexus, they typically affect the upper cer-
vical roots and superior trunk, causing pain more commonly
in a median or radial nerve distribution.
The lumbar and sacral plexus provide innervation to the
lower extremity. The lumbar plexus is comprised of the ven-
S. L. Thorp
tral rami of the L1–L4 spinal nerves, with variable contribu-
tions from the T12 and L5 spinal nerves. The plexus lies in
the psoas compartment located between the quadratus lum-
borum and psoas muscles and is composed of dorsal and
ventral divisions. The main branches of the lumbar plexus
include the femoral, obturator, and lateral femoral cutaneous
nerves as well as the iliohypogastric, ilioinguinal, and geni-
tofemoral nerves. The sacral plexus arises from S1–S3 giv-
ing rise to the sciatic nerve posteriorly, which then forms the
common peroneal and tibial nerves, as well as the pudendal
nerve which provides sensation to the perineal area.
The most common tumors invading this plexus are
colorectal, sarcomas, and genito-ureteral tumors, with the
sacral plexus being involved more commonly than the lum-
bar plexus. When the lumbar plexus is involved, the most
common presenting symptom is leg pain, followed by numb-
ness and weakness [11]. As the plexus lies in the psoas com-
partment, tumors affecting the psoas muscle can cause
significant pain, termed malignant psoas syndrome [12].
When the sacral plexus is involved, the clinical picture can
present with pain down the posterior aspect of the leg and
weakness in the foot, similar to an S1 radiculopathy. The
patient may also present with perineal pain and incontinence
in later stages. Diagnosis of neoplastic plexopathy is con-
firmed with magnetic resonance imaging (MRI) and positron
emission tomography (PET) to identify areas of active neo-
plasm in or abutting the plexus. Electromyography (EMG)
can be used to further elucidate which nerves are most
affected and guide treatment.
 ther Associated Pathophysiology
O
for Anatomic Cancer-Related Pain
While pain related to tumor in the bone and nervous system
structures is the most common cause of anatomical pain,
other anatomical locations may generate pain as well.
Tumors in the brain are well known to cause headaches, as
are metastasis to the spinal meninges [13]. Distension of
capsular organs is another well-known cause of tumor-­
related pain as occurs when liver tumors distend Glisson’s
capsule causing abdominal pain [14]. In all of these exam-
ples, the primary treatment of cancer pain is treatment of the
cancer and any therapies that remove or reduce the size of the
tumor.
Chemical Mediators of Pain
The tumor microenvironment (TME) is composed of tumor
cells and stromal cells and has a substantial role in tumor
progression and cancer-mediated pain [15]. Tumor and stro-
mal cells communicate with each other, their microenviron-
3 Pathophysiology of Cancer Pain 15

ment, as well as the tissue they are invading by secreting In addition to inflammatory cytokines inducing inflamma-
multiple noxious chemical factors, inflammatory mediators, tion and sensitization of peripheral nociceptors, cytokines
and immunomodulators. These stimuli are transduced at may also be involved in noninflammatory pain. TGF-β is a
peripheral nociceptors and transmitted via an action poten- cytokine that has been implicated in regulating osteoclasts
tial to the spinal cord and travel via ascending tracts to the and mediating bone resorption, as occurs with metastasis to
supraspinal processing centers. While this likely plays a role bone. TGF-β is released by chondrocytes during bone injury
in all cancers, the details of a few specific examples have and may mediate the production of nerve growth factor
been elucidated. (NGF) in chondrocytes as well [19]. Further, TGF-β has been
shown to be inhibited by proinflammatory cytokines and, as
such, may be a noninflammatory mediator of pain in meta-
 athophysiology of Pain in Patients
P static bone pain. The stimulation of osteoclastogenesis may
with Multiple Myeloma also lead to the release of growth factors and other mediators
that may cause the growth of the invading tumor cells.
Multiple myeloma is a malignant cancer of plasma cells that
results in a unique pain syndrome referred to as myeloma
bone disease. Bone pain is the most common symptom Novel Therapies for Cancer-Related Pain
reported at presentation, in more than two-thirds of patients,
and 80–90% of patients with multiple myeloma will develop The treatment of cancer pain is multifaceted and discussed
bone lesions during their disease [16]. The etiology of this throughout this text. The most important treatment of cancer
bone pain is likely dysregulation in bone remodeling. Normal pain is treatment of the cancer itself. Treatments in the form
bone remodeling is a continuous process of old bone resorp- of surgery, radiation therapy, chemotherapy, interventional
tion stimulated by osteoclasts and new bone formation treatments, and medication management are at the forefront
through collagen synthesis and mineralization by osteo- of treatment. These treatments may be the cause of, or con-
blasts. When multiple myeloma metastasizes to the bone, it tribute to, the patient’s pain as well, as with chronic postsurgi-
induces bone resorption by activating osteoclasts. The cal pain, radiation-induced neuritis, or chemotherapy-induced
myeloma cells release and stimulate cells in the bone mar- peripheral neuropathy, to name a few examples. In recent
row microenvironment to release osteoclastogenic activating years there has been increased interest in treatments that tar-
factors such as RANKL, MIP-1α, TNF-α, interleukin 3 (IL-­ get the pathophysiology of the cancer. These same molecular
3), and IL-6 [17]. In addition to the stimulation of osteoclast targets are also potential targets for the treatment of pain, as
formation and activity, many of these factors are also these therapies that target the cytokine and inflammatory
involved in the inhibition of osteoblastic activity as well as amediators released by tumors and inhibit tumor growth also
supportive role for myeloma cells themselves. decrease tumor-related pain.
Bone-related pain and the molecular causes of the pain
are now being targeted as pain therapies. One such molecule
Pathophysiology of Cancer Pain in Patients is Src, a protein tyrosine kinase non-receptor that is associ-
with Breast Cancer ated with the N-methyl-D-aspartate (NMDA) receptor com-
plex. Found in neurons, Src has been shown to be associated
Breast cancer, in addition to causing pain with metastasis to with pain and maintaining inflammatory hyperalgesia [20].
sites such as the bone and compressing neural structures as Further, Src has a vital role in osteoclast activity. By target-
discussed previously, causes pain through the release of ing this molecule involved in bone resorption, there is poten-
chemical mediators as well. The tumor and stromal cells tial to decrease the breakdown of bone and thus one aspect of
release and induce host release of numerous mediators of the bone pain itself. Bisphosphates are another well-known
pain. The amount and content of circulating cytokines have treatment that inhibits osteoclast-mediated bone resorption
been shown to be not only distinct to subtype of breast can- by reducing osteoclast activity [21]. While effective in reduc-
cer but potentially to the amount of pain suffered by patients ing osteoclastic activity, bisphosphonates do not impact
as well. Luminal type A and B breast cancers exhibit higher osteoblastic activity and have numerous potential side effects
levels of TGF-β1 and TNF-α than healthy controls, and TGF-­ including renal impairment and osteonecrosis of the jaw.
β1 levels are higher in HER2-amplified tumors than luminal Further, bisphosphonates have been shown to inhibit the
types [18]. In contradistinction, triple-negative tumors have ability of the metastasis to interact with the osteoblasts and
lower circulating levels of TGF-β1 when compared with inhibit their secretion of chemokine CCL2 [22].
other subtypes and healthy volunteers. While the different The treatment of myeloma bone disease is multifaceted
cytokine profiles of tumors are currently under investigation, and involves mediation management, radiation therapy, che-
the direct relationship with pain is still being elucidated. motherapy, vertebral augmentation, and surgery. The under-
16
Table 3.1 Potential targets for the treatment of myeloma bone
disease
Osteoclast mediators Osteoblast mediators
OPG WIF-1
RANK SFRPs
MIP-1 alpha Dkk
VEGF Runx2
SDF-1 alpha TGF-beta
OPG osteoprotegerin, RANK receptor activator of nuclear factor kappa-
­B, MIP-1 alpha macrophage inflammatory protein-1 alpha, VEGF vas-
cular endothelial growth factor, SDF-1 alpha stromal-derived factor-1
alpha, WIF-1 wnt inhibitory factor-1, SFRPs secreted frizzled-related
proteins, Dkk Dickkorf family of secreted proteins, Runx2 runt-related
transcription factor 2, TGF-beta transforming growth factor-beta
lying pathophysiology discussed previously has also become
a target for therapy. Bisphosphonates, discussed previously,
are a mainstay of therapy for multiple myeloma. In addition
to bisphosphonates, a number of mediators known to be
involved in the pathogenesis of myeloma bone pain are cur-
rently being investigated as potential therapeutic targets, and
there is tremendous potential for such agents (Table 3.1).
One such agent, bortezomib, is a proteasome inhibitor that
has been found to improve the survival of patients with mul-
tiple myeloma [23].
Pain related to breast cancer may be related to many of the
topics discussed previously, including compression of neural
structures and metastasis to bone. As in the treatment of
myeloma bone pain, there are many potential novel therapies
being investigated that may be used to not only treat the cancer
but the pain it causes as well. It has been shown that altered
glutamatergic signaling can disrupt the normal cycle of bone
remodeling and cause significant pain [24]. Utilizing inhibi-
tors of glutamate release from the cancer cells is one such 10. Jaeckle K. Neurologic manifestations of neoplastic and radiation-­
novel therapeutic approach. Sulfasalazine is an inhibitor of
glutamate release that has been shown to reduce nociceptive 11. Jaeckle KA, Young DF, Foley KM. The natural history of lumbosa-
behavior in a mouse model of breast cancer bone pain [25]. 12. Stevens MJ, Atkinson C, Broadbent AM. The malignant psoas syn-
The continued investigation of further treatments related to the
pathophysiology of breast cancer pain will continue to change
the management of the cancer itself and the pain it causes.
Conclusion
Cancer pain is difficult to treat and a terrible malady for
those suffering from cancer. Traditional therapies continue to
be the standard of care and involve medication management, 15. Quail DF, Joyce JA. Microenvironmental regulation of tumor pro-
radiation therapy, chemotherapy, vertebral augmentation,
and surgery, among other therapies. New studies that eluci-
date the pathophysiology of individual cancers open the door
for novel therapies that may target the cancers as never done 17. Edwards CM, Zhuang J, Mundy GR. The pathogenesis of the bone
before. As new therapies evolve, the treatment of cancer-­
related pain will evolve as well, ushering in a new paradigm
of treatment for our patients.
S. L. Thorp
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 Chemotherapy
4
Karina Gritsenko and Michael Lubrano

Introduction affect all phases of the cell cycle, with the majority focusing
on S phase (antimetabolites) or M phase (taxanes and vinca
In this chapter, the most common chemotherapeutic agents, alkaloids) [2–5]. A summary of antineoplastic agents, by
a number of their uses, and most of their relevant side effects class, is included in Table 4.1.
are addressed. For some compounds, their uses may extend
further than just neoplastic therapies as a number of inflam-
matory diseases benefit from immune modulation. For the Alkylating Agents
purposes of our review, only antineoplastic uses and their
adverse effects will be mentioned. Alkylating agents are a large and diverse class of agents that
actively cross-link DNA strands in order to reduce the syn-
thesis of DNA during all steps of the cell cycle. Subcategories
Chemotherapeutic Classes include alkyl sulfonates, bioreductives, nitrogen mustards,
nitrosoureas, and triazenes. Alkyl sulfonate (busulfan) pri-
Chemotherapeutic agents are subdivided into major classes marily interacts with guanosine at the N-7 position in order
and then subcategories. Therapies are grouped according to to disrupt RNA transcription and the replication of DNA. It
which component of the cell cycle they impair and the mech- is especially effective in hematologic cells with considerable
anism by which this occurs. Tumor cells are rapidly growing, efficacy on myeloid cells compared to lymphoid cells. Alkyl
and dividing entities thus are more susceptible to interven- bioreductives (mitomycin C) are most active during late-G1
tions that impair cellular division, triggering a cascade and early-S phases of the cell cycle. It is converted to an
toward cell destruction. The cycle for somatoform non-­ alkylating metabolite and functions as such by cross-linking
gamete developing cells begins with G1 phase. The cell pre- nucleotides, primarily guanine and cytosine, thus disrupting
pares for division by expressing RNA and proteins which cell activity. DNA and RNA syntheses are also impaired.
allow the cell to grow in anticipation of future cell division. Reduced environments, such as hypoxic tumor cells, increase
The next phase, S, allows for DNA replication. G2 phase the effectiveness of this agent. Nitrogen mustards (cyclo-
subsequently occurs with a number of checkpoints to assure phosphamide, mechlorethamine, melphalan, chlorambucil)
the cell is ready to appropriately divide. The final phase is M include a myriad of agents that are effective in cross-linking
phase, which occurs directly before cell division, with its DNA strands to impair DNA synthesis. As such, they are
hallmark mitotic spindle that develops down the center of a active during all phases of the cell cycle. Nitrosoureas (car-
cell prior to division, aligning and separating chromosomes mustine, lomustine, semustine, streptozocin) also cross-link
to opposite, cellular poles [1]. Chemotherapeutic agents may DNA and RNA strands but may have a secondary function of
modifying and disrupting proteins as well. Given their lipid-­
soluble nature, nitrosoureas are able to cross the blood-brain
K. Gritsenko (*)
barrier in order to treat tumors of the central nervous
Montefiore Medical Center – Albert Einstein College of Medicine,
Bronx, NY, USA system.
Busulfan is an alkylating agent used in chronic myeloge-
M. Lubrano
Department of Anesthesia & Perioperative Care, University of nous leukemia with up to 90% remission. Seizures have been
California San Francisco (UCSF) Medical Center, reported in patients who are predisposed to them, and pro-
San Francisco, CA, USA phylactic anticonvulsants may be administered prior to
e-mail: Michael.Lubrano@ucsf.edu

© Springer Nature Switzerland AG 2019 19

A. Gulati et al. (eds.), Essentials of Interventional Cancer Pain Management, https://doi.org/10.1007/978-3-319-99684-4_4
20 K. Gritsenko and M. Lubrano

Table 4.1 Summary of agents

Class Agent Uses Adverse effects
Alkyl Busulfan CML Adrenal insufficiency, bone marrow
sulfonate suppression, seizures, pulmonary fibrosis,
hepatic sinusoidal obstruction syndrome,
cardiac tamponade
Bioreductive Mitomycin C Adenocarcinomas of the stomach/pancreas, anal Bladder fibrosis, hemolytic uremic
carcinoma, bladder cancer, cervical cancer, esophageal syndrome, pulmonary toxicity
cancer, non-small cell lung cancer
Nitrogen Cyclophosphamide Breast cancer, ALL/AML/CLL/CML, Ewing’s sarcoma, Acute respiratory distress syndrome, bladder
mustard Hodgkin’s/non-Hodgkin’s lymphoma, multiple myeloma, cancer, cardiotoxicity, hemorrhagic cystitis,
mycosis fungoides, pheochromocytoma, small-cell lung infertility, pneumonitis
cancer, Wilm’s tumor
Nitrosourea Carmustine Astrocytomas, ependymomas, glioblastomas, Bone marrow suppression, ocular toxicity,
medulloblastomas, multiple myeloma, Hodgkin’s/ pulmonary toxicity, renal impairment
non-Hodgkin’s lymphoma, mycosis
Nitrosourea Streptozocin Adrenal carcinoma, pancreatic islet cell carcinoma Bone marrow suppression, glucose
intolerance, confusion/lethargy, depression
Triazene Dacarbazine Melanoma, Hodgkin’s lymphoma, medullary carcinoma Anaphylaxis, extravasation
pheochromocytoma, medullary carcinoma
Triazene Temozolomide Gliomas, refractory astrocytoma Pneumocystis jirovecii pneumonia
Folate Methotrexate Acute lymphoblastic leukemia, breast cancer, central Acute kidney injury, bone marrow
nervous system tumors, head and neck cancer, lung suppression, dermatologic reactions,
cancers, meningeal leukemia, trophoblastic neoplasms diarrhea/stomatitis, infertility,
hepatotoxicity, neurotoxicity, pneumonitis,
tumor lysis syndrome
Folate Pemetrexed Bladder cancer, cervical cancer, ovarian cancer, pleural Bone marrow suppression,
mesothelioma, non-squamous non-small cell lung cancer, dermal reactions, GI toxicity, hepatotoxicity,
thymus cancer interstitial pneumonitis
Platinum Cisplatin Bladder cancer, breast cancer, cervical cancer, endometrial Anaphylaxis, extravasation, hyperuricemia,
analog cancer, esophageal and gastric cancer, hepatobiliary cancer, gastroenteric toxicity, neurotoxicity,
Hodgkin’s lymphoma, testicular cancer, ovarian cancer, ototoxicity, renal toxicity, posterior
neuroblastoma, neuroendocrine tumors reversible leukoencephalopathy syndrome
(PRES)
Platinum Carboplatin Advanced ovarian cancer, Merkel cell carcinoma, Similar to cisplatin with less gastrointestinal
analog small-cell lung cancer, thymic malignancies, others similar and renal toxicity
to cisplatin
Platinum Oxaliplatin Colorectal cancer, esophageal cancer, gastric cancer, Anaphylaxis, GI toxicity, neuropathy,
analog pancreatic cancer, hepatobiliary cancer, ovarian/testicular hepatic toxicity, pulmonary fibrosis,
cancer posterior reversible leukoencephalopathy
syndrome (PRES)
Purine analog Mercaptopurine Acute lymphoblastic leukemia, acute promyelocytic Bone marrow suppression, hepatotoxicity,
leukemia, non-Hodgkin’s lymphoma immunosuppression, secondary
malignancies
Purine analog Thioguanine Adult acute myelogenous leukemia Bone marrow suppression, hepatotoxicity,
malignancies, tumor lysis syndrome
Purine analog Hydroxyurea Chronic myelocytic leukemia, ovarian cancer, melanoma, Bone marrow suppression, megaloblastic
meningiomas, squamous head and neck cancer erythropoiesis, vascular ulceration,
gangrene, secondary malignancy, tumor
lysis syndrome
Pyrimidine 5-Fluorouracil Breast cancer, bladder cancer, colon cancer, gastric cancer, Palmar-plantar erythrodysesthesia (hand-­
analog (5-FU) head and neck cancers, hepatobiliary cancers, foot) syndrome, diarrhea, neurotoxicity,
neuroendocrine cancers, pancreatic cancer neutropenia
Pyrimidine Capecitabine Metastatic colon cancer, similar tumor profile as 5-FU Bone marrow suppression, cardiotoxicity,
analog gastrointestinal toxicity, hand-foot
syndrome, hepatotoxicity
Pyrimidine Cytarabine Acute lymphocytic leukemia, acute myelocytic leukemia, Acute pancreatitis, bone marrow
analog chronic myelocytic leukemia in blast phase, chronic suppression, hypersensitivity, respiratory
lymphocytic leukemia, meningeal leukemia, refractory arrest, tumor lysis syndrome
Hodgkin’s lymphoma
4 Chemotherapy 21

Table 4.1 (continued)

Class Agent Uses
Pyrimidine Gemcitabine Bladder cancer, cervical cancer, Hodgkin’s/non-Hodgkin’s
analog lymphoma, metastatic breast cancer, non-small cell lung
cancer, ovarian cancer, pancreatic adenocarcinoma, renal
cell cancer, small-cell lung cancer, sarcomas, testicular
cancer, thymic malignancies
Anthracycline Doxorubicin Acute lymphocytic leukemia, acute myeloid leukemia,
breast cancer, sarcomas of the soft tissues and bone,
thyroid cancer, small-cell lung cancer, gastric cancer,
neuroblastoma, Wilm’s tumor
Antibiotic Bleomycin Cervical cancer, penis carcinoma, head and neck squamous
cell carcinoma, Hodgkin’s/non-Hodgkin’s lymphoma,
ovarian germ cell tumors, testicular carcinoma
Vinca alkaloid Vincristine Acute lymphocytic leukemia, chronic lymphocytic
leukemia, Ewing’s sarcoma, gestational trophoblastic
tumors, Hodgkin’s/non-Hodgkin’s lymphoma, multiple
myeloma, small-cell lung cancer, Wilm’s tumor,
neuroblastoma, retinoblastoma, rhabdomyosarcoma
Vinca alkaloid Vinblastine Bladder cancer, breast cancer, choriocarcinoma desmoid
tumors, Hodgkin’s/non-Hodgkin’s lymphoma, Kaposi’s
sarcoma, melanoma, ovarian cancer, testicular cancer
Taxane Paclitaxel Adenocarcinoma, bladder cancer, breast cancer, head and
neck cancers, Kaposi’s sarcoma, non-small cell lung
cancer, ovarian cancer, small-cell lung cancer
Adverse effects
Bone marrow suppression, capillary leak
syndrome (CLS), hemolytic uremic
syndrome (HUS), pulmonary toxicity
Bone marrow suppression, cardiac toxicity,
secondary malignancy, skin extravasation,
tumor lysis syndrome
Hepatotoxicity, renal toxicity, pulmonary
toxicity, idiosyncratic reaction
Gastrointestinal toxicity, neurotoxicity,
respiratory complications, uric acid
nephropathy
Disabling neurotoxicity, peripheral sensory
neuropathy
Bone marrow suppression, cardiovascular
toxicity, hypersensitivity reactions,
peripheral neuropathy

t­herapy initiation in cases where high doses may be antici-
pated. Pulmonary fibrosis and bronchopulmonary dysplasia
can occur with an average of 4 years after treatment in up to
4% of patients. Hepatic sinusoidal obstruction syndrome
may occur and is associated with high concentrations as a
result of rapid infusion. This risk is increased with doses over
16 mg/kg based on ideal body weight. With pulmonary
symptoms, it is important to rule out opportunistic infections
as well as leukemic infiltrates before diagnosing busulfan
toxicity. This may require biopsy of the lung. If toxicity is
diagnosed, busulfan should be discontinued immediately.
Mitomycin C is an alkylating agent effective against a
number of GI adenocarcinomas. It can be used alongside
5-fluorouracil for squamous cell cancer of the anus. As a
vesicular infusion, it may also be used to topically treat blad-
der cancer. Bladder fibrosis is a common side effect. Patient
may also experience pulmonary toxicity and hemolytic ure-
mic syndrome.
Cyclophosphamide is a nitrogen mustard most frequently
utilized clinically in a large number of oncologic and inflam-
matory settings, including hematologic, adrenal, and lung
cancers. Hepatocytes metabolize cyclophosphamide to aldo-
phosphamide, which is further converted into toxic com-
pounds by cells throughout the body, including target tumor
cells. These toxic compounds thus function as alkylating
agents. High doses of cyclophosphamide may cause cardio-
toxicity by damaging endothelial capillaries. This can lead to
pericarditis or pericardial effusions and may eventually
develop into a cardiac tamponade [6]. ACE inhibitors, ino-
tropes, beta-blockers, and diuretics can help to manage car-
diotoxicity. Pneumonitis is rare and can be reversed with
early discontinuation within the first several months of use.
Pleural thickening is associated with late-onset pneumonitis
which may become a chronic, progressive condition [7].
Interstitial cystitis and bladder cancer are additional con-
cerns, as acrolein (a toxic metabolite of cyclophosphamide)
may accumulate in the bladder, thus predisposing transi-
tional bladder cells to oncogenicity. In order to avoid these
toxic side effects, clinicians should consider pulse doses as
well as giving 2-mercaptoethanesulfonate, a compound that
conjugates acrolein in the urine. Patients should also be
advised to drink fluids to maintain adequate hydration. Of
note, some individuals with a G516 T variant of CYP2B6
metabolize cyclophosphamide much more rapidly and there-
fore may require lower doses in order to avoid the toxic
effects of this agent.
Carmustine is similar to other nitrosoureas as it cross-­
links DNA and RNA strands. It may also carbamylate amino
acids which modify proteins. This agent is lipid soluble, thus
allowing it to cross the blood-brain barrier in order to combat
malignancies in the central nervous system (including astro-
cytomas, ependymomas, glioblastomas, and medulloblasto-
mas). Cumulative doses greater than 1400 mg/m2 place
patient at risk for delayed-onset pulmonary fibrosis typically
in those who have had prolonged treatment.
Streptozocin is a nitrosourea that functions similarly to
carmustine by cross-linking DNA, modifying proteins, and
crossing the blood-brain barrier. It is typically used to treat
metastatic islet cell carcinoma of the pancreas and metastatic
adrenal carcinomas. Patients experience less bone marrow
22 K. Gritsenko and M. Lubrano

suppression for this agent than for carmustine, although it metabolite that allows for its elimination. Tumor lysis syn-
has been associated with psychiatric side effects such as drome is another severe side effect that may lead to acute
depression and confusion. kidney injury and/or failure, especially when tumor burden
Dacarbazine is a triazene that is activated by the cyto- is high.
chrome P450 system by conversion to methyl-triazene-1-l- Pemetrexed functions similarly to methotrexate but also
imidazole-­4-carboxamide (MTIC). As MTIC, it functions by inhibits thymidylate synthase and two other enzymes that
methylating the O6 and N6 positions of guanine in DNA. This play roles in the reduction of folate. Its uses include treating
subsequently causes breaks in the DNA double strand and pleural mesothelioma and thymus cancer. Bone marrow sup-
eventual triggers apoptosis. It may be used for treating mela- pression and interstitial pneumonitis are concerning adverse
noma and adrenal malignancies. Extravasation is a serious effects; however, hepatic toxicity is especially concerning
consequence that results in extreme pain and tissue damage. with pemetrexed with several case reports identifying this as
Temozolomide: This prodrug is converted to MTIC non- a cause of mortality. Folate and vitamin B12 are essential for
enzymatically through a spontaneous and rapid process in reducing bone marrow and gastrointestinal toxicity.
bodily tissues after redistributing. It functions similar to
dacarbazine as a triazene. Typically, this agent is reserved for
refractory astrocytoma and a number of additional, off-label Nucleotide and Platinum Analogs
uses in the central nervous system tumors. Radiotherapy in
conjunction with this agent increases risk for Pneumocystis Nucleotide analogs are broken down into two subgroups.
jirovecii pneumonia, thus warranting prophylactic antibiot- Purine analogs (mercaptopurine, thioguanine, hydroxyurea)
ics in select patient populations. mimic adenosine and guanine. They typically deceive intra-
cellular machinery in order to be inappropriately placed into
DNA. Once present, DNA replication is impaired, and tumor
Folates cells are unable to undergo S phase and replicate. This trig-
gers a number of mechanisms that lead to apoptosis.
Folates participate in a disruption of the folate cycle (metho- Pyrimidine analogs (fluorouracil, capecitabine, cytaragine,
trexate, pemetrexed). These agents irreversibly inhibit dihy- gemcitabine) either mimic cytosine, thymine, and uracil or
drofolate reductase (DHFR), an enzyme that donates methyl entirely block pyrimidine synthesis within cells. These
groups to folate, thus impairing an essential step for intracel- agents commonly are administered as prodrugs that require
lular production of purines and thymidylic acid. DNA, RNA, activation by either hepatic cells or cellular machinery within
and various proteins require this in order to function. While the tumor of interest.
folates may also be used in inflammatory diseases, the mech- Platinum analogs (carboplatin, cisplatin, and oxaliplatin)
anism of action is unknown. effectively treat malignancies by interacting with tumors in a
Methotrexate is a folate that is especially useful in treat- number of ways. They actively bind the DNA of target cells
ing solid tumors found in a myriad of organ systems. It is and form intra-strand and inter-strand DNA covalent cross-­
often the agent of choice for trophoblastic neoplasms and links. These cross-links inhibit DNA synthesis and denature
may be given as a sole agent for hydatidiform moles or ecto- the double helix.
pic pregnancies of small enough sizes. The hepatotoxic side Mercaptopurine is a purine analog converted by
effects of methotrexate are related to a cumulative dose of hypoxanthine-­guanine phosphoribosyl transferase (HGPRT)
greater than 1.5 grams. Hepatic biopsies are recommended into monophosphate and triphosphate forms. The mono-
in patients with prolonged exposure. Other hepatotoxic risk phosphate form inhibits purine synthesis. The triphosphate
factors include ethanol consumption, diabetes, hyperlipid- form is falsely incorporated into DNA and RNA by cellular
emia, family history of liver disease, and obesity. machinery to inhibit replication. Xanthine oxidase (XO) is
Methotrexate elimination is renal based, with greater than the enzyme that metabolizes its active forms, as well as
50% not metabolized. Neurotoxicity includes seizures that purines themselves. By co-administering allopurinol, a XO
occur predominantly in children who are being treated for inhibitor, the dose of mercaptopurine can be reduced by
ALL, as well as encephalopathy from high doses or concur- 50–70%. Mercaptopurine is mainly used for hematologic
rent radiation. Intrathecal administration raises concerns for cancers and thus has a number of side effects involving the
arachnoiditis, chronic leukoencephalopathy, and myelopa- manipulation of hematologic cell lines. This includes bone
thy. Administering leucovorin (5-formyltetrahydrofolate) marrow suppression, immunosuppression, and subsequent
may reduce the toxicity of methotrexate and spares non-­ secondary malignancies. Hepatotoxicity occurs at any dose,
tumor cells. Another treatment modality for overexposure but increased risk occurs above 2.5 mg/kg/day.
includes glucarpidase, an enzyme that rapidly hydrolyzes Discontinuation may resolve hepatic symptoms after about
methotrexate in the extracellular space into an inactive 1–2 months. Secondary malignancies are a major concern,
4 Chemotherapy
especially hepatosplenic T-cell lymphomas (HSTCL) which
are a rare and frequently fatal cancer.
Thioguanine is a purine analog closely related to mercap-
topurine and has a similar function and metabolism. Its pri-
mary use is for adult acute myelogenous leukemia. Side
effects parallel those of mercaptopurine with concern for
tumor lysis syndrome. Some patients have genetic polymor-
phism that results in a deficiency of thiopurine methyltrans-
ferase (TPMT). Medications that are salicylic acid derivatives
are able to inhibit TPMT and may lead to significant myelo-
suppression while taking this agent for some patients. This
would require considerable dose reduction to avoid serious
toxicity.
Hydroxyurea is another purine analog that disrupts DNA
synthesis by inhibiting ribonucleoside-diphosphate reduc-
tase. This blocks the development of deoxyribonucleotides
from ribonucleotides, thus freezing target cells in the G1
phase. It is effective in leukemias, melanoma, and squamous
cancers. In addition to tumor lysis syndrome, concerning
adverse effects include bone marrow suppression, megalo-
blastic erythropoiesis, vascular ulceration, and gangrene.
Erythrocyte abnormalities may erupt displaying megaloblas-
tic erythropoiesis that is typically self-limiting. Hydroxyurea
has also been associated with the development of skin cancer
with long-term use.
5-Fluorouracil (5-FU) is a pyrimidine analog requiring
activation in order to inhibit thymidylate synthase. This
enzyme is necessary for generating thymidine triphosphate,
an essential factor for synthesizing DNA. A second metabo-
lite of 5-FU is generated that may be inappropriately incor-
porated in RNA and effectively disrupt translation. This is a
very useful agent to treat solid tumors found throughout mul-
tiple organ systems. Palmar-plantar erythrodysesthesia
(hand-foot) syndrome is a side effect that 5-FU may precipi-
tate that involves tingling in the hands and feet. It has the
potential for developing into pain associated with erythema.
The resolution typically occurs within a week of discontinu-
ing 5-FU. Toxicity can also occur in the 5% of patients who
are deficient in dihydropyrimidine dehydrogenase (DPD),
the enzyme responsible for metabolizing 5-FU. Without
DPD, 5-FU toxicity can cause neutropenia, diarrhea, and
neurotoxicity. Overdose of 5-FU may be treated with uridine
triacetate if administered within 4 days, with multiple, small
cohort studies showing full recovery in all patients who
received this rescue agent [8, 9].
Capecitabine is another pyrimidine analog (prodrug) that
must be hydrolyzed by the liver as well as other bodily tis-
sues to become 5-FU. Its uses are therefore similar to 5-FU,
but it is capable of oral administration. Its side effect profile
is similar; although bone marrow suppression is significant,
patients with platelets less than 100,000 or neutrophils less
than 1500 are not candidates for this medication.
Dysrhythmia, angina, myocardial infarction, cardiac arrest,
23
cardiac myopathy, and sudden death have all occurred in
patients receiving capecitabine.
Cytarabine, a pyrimidine analog, utilizes cellular trans-
porters to enter tumors prior to being converted to aracyti-
dine triphosphate. In this phosphorylated form, it may be
placed into DNA. Unlike other analogs, cytarabine functions
by directly inhibiting DNA polymerase, both alpha and beta,
thus impairing DNA replication and repair, primarily useful
to treat hematologic malignancies. In addition to acute pan-
creatitis and tumor lysis syndrome, a hypersensitivity reac-
tion with acute cardiopulmonary arrest is a rare side effect.
Sudden respiratory arrest syndrome is also a subsequent con-
cern that may take up to 12 h to precipitate following treat-
ment. This involves malaise, maculopapular rash, fever,
myalgia, bone pain, and chest pain and requires immediate
administration of corticosteroids to manage. Patients receiv-
ing doses that exceed 1.5 g/m2 may experience
conjunctivitis.
Gemcitabine is also a pyrimidine analog that functions
similarly to cytarabine. It is metabolized to gemcitabine
diphosphate and works to inhibit ribonucleotide reductase
and DNA synthesis. Its triphosphate form is effective in
incorporating itself into DNA directly to inhibit DNA poly-
merase. This agent is used to treat metastatic breast cancer
and solid and hematopoietic tumors from a number of organ
systems. Capillary leak syndrome (CLS) and hemolytic ure-
mic syndrome (HUS) are serious, adverse events.
Gemcitabine should be discontinued if CLS precipitates.
HUS may result in considerable morbidity and mortality.
Any patient on this agent must therefore have an established
renal baseline that is continuously monitored. Adult respira-
tory distress syndrome and pneumonitis and fibrosis are
other observed effects although symptoms may not precipi-
tate for 2 weeks after a patient’s gemcitabine dose.
Cisplatin is a platinum analog that exists in two isomer
forms, with the cis form actively functioning at 14 times the
cytotoxic level as its trans-isomer counterpart. Both isomers
function similarly, but cellular mechanisms are less capable
of recognizing and repairing the cis-isomer form. It is effec-
tive in eradicating a number of tumor cells, most notably
solid tumors. Adverse effects are also numerous and consid-
erable – perhaps the most notable including ototoxicity and
renal toxicity. Neurotoxicity is an additional concern for all
platinum agents. Hyperuricemia may also occur with cispla-
tin due to tumor lysis. Neuropathies that are severe and
potentially irreversible can occur when administration is too
frequent or recommended doses are exceeded. A number of
neurologic sequelae have been described, including posterior
reversible leukoencephalopathy syndrome (PRES), seizures,
and loss of taste or motor function. Children with thiopurine
S-methyltransferase (TPMT) polymorphisms are more sus-
ceptible to ototoxicity, which is also dose dependent and per-
petuated by aminoglycoside use.
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN