The UNITARIAN OR TROPHOBLASTIC THESIS OF CANCER AND NITRILOSIDES (VITAMIN B-17) Ernst T. Krebs Jr. & Enrst T. Krebs Sr. Laetrile Crystal Table of Contents 1. The Unitarian or Trophoblastic Thesis of Cancer p. 1 2. Cancer or Cancers? p. 27 3. The Pathology of The Trophoblast p. 31 4. The Nature of Cancer p. 32 5. The Role of The Trophoblast and The Pancreas (The Pregnancy Toxemias) p. 38 6. The Nitrilosides (Vitamin B-17) – Their Nature, Occurence and Metabolic Significance (Antineoplastic Vitamin B-17) p. 58 7. The Nitrilosides in Plants And Animals – Nutritional and Therapeutic Implications p. 69 8. The Extraction, Identification and Packaging of Therapeutically Effective Amygdalin p. 91 9. Trophoblast Elements in Cancer p. 98 This book is a compilation of all the available scientific papers written by Ernst T. Krebs, Jr. and Sr., relating to the Unitarian or Trophoblastic Thesis of Cancer and the Identification and Use of Nitrilosides (Vitamin B-17) as a first aid therapy in the management of cancer. Along the authors mentioned above, other writers involved in the research of these scientific papers are Howard H. D. Beard, Clifford L. Barlett and Charles Gurchot. THE UNITARIAN OR TROPHOBLASTIC THESIS OF CANCER by Ernst T. Krebs, Jr.,* Ernst T. Krebs, Sr.,** and Howard H. Beard*** (Reprinted From the Medical Record, 163:149-174, July 1950) It is veritably impossible to find, among the hundreds of valid experimental contributions to our knowledge of cancer made during the past half century, an experimentally established datum that would controvert the thesis of the basic biological uniformity characterizing all exhibitions of cancer. THE CRITERIA OF UNIFORMITY To the experimentalist who does not overtly accept an unitarian thesis of cancer, such a thesis is still implicit in the commonplace facts of his science. The classic experiments of Warburg on the respiratory pattern of cancers of various species and tissue origins reveal a high uniformity from tumor to tumor.1 Correlatively, the Coris find the lactic acid and sugar content of the various exhibitions of cancer to be highly uniform.2 Williams and his co-workers report a pronounced degree of uniformity in the concentration of eight B vitamins in a great variety of animal and human tumors, regardless of the tissue of origin or the manner of their induction.3 Robertson makes similar observations for vitamin C.4 The addition of various substrates to malignant tumors of various types yields highly uniform respiratory responses.5 Shack describes an almost complete uniformity in cytochrome oxidase content in a number of mouse tumors. 6 Greenstein finds that the presence of any exhibition of cancer uniformly results in a depression of the liver catalase. 7,8 Maver and Barrett describe substantial evidence for an immunological uniformity among malignant tumors.9 Greenstein reports an impressive degree of uniformity in enzyme concentration among malignant tissues, regardless of their means of induction, tissue of origin or species of origin. 10 Others describe a uniformly low content of such aerobic catealytic systems as cytochrome, succinic, and d- amino acid oxidases, cytochrome-c, catalase and flavin.11,12,13,14,15,16,17 Further phenomena of uniformity are observed in the elevated water and cholesterol content of malignant tumors as well as other primitive tissues.18,19 The induction by a single steroid carcinogen, such as methylcholanthrene, of malignant exhibitions as diverse as leukemia and malignant melanoma, attests to a basically uniform etiology. The uniformity of various exhibitions of cancer in respiratory properties, lactic acid production, vitamin content, enzyme content, action on a given substrate, effect on liver catalase, cytochrome oxidase content immunological properties, and many other characteristics is correlative to an uniformity of ------ * We wish to acknowledge the helpful suggestions and criticisms on the trophoblastic thesis from Clifford L. Bartlett, M.D., Pasadena, California; John Bodman, M.D., London, England; and Arthur Harris, M.D., North Hollywood, California. 1 **John Beard Memorial Foundation, 642 Capp Street, San Francisco, California ***Cancer Clinic, Holy Cross Hospital, Chicago, Illinois. [Page 150..of Annual Collection] malignant tumors in the ability to metastasize, in their amenability to heterotransplantability, 21, 22 and in their autonomy, invasiveness and erosiveness. Indeed, there is no known basic property unique to any single exhibition of cancer---the only variation being a morphological one partially conditioned by admixed benign or somatic components. The degree in the uniformity of the factors described increases with the increasing malignancy with which the tumor is exhibited. Thus with an increasing degree of malignancy, all malignant exhibitions converge toward a common tissue type. For this reason the cells of the most malignant of all exhibitions of cancer should epitomize the properties of the malignant component in all other exhibitions of cancer. That this is the case, we shall observe in the pages that follow. We have glanced briefly at data that are commonplace to cancer research. The logical consequences of these data have, however, seldom been examined. Since the phenomenon of cancer is truly an unitarian one, then, of logical necessity, the variations in the biological malignancy of different exhibitions of cancer must be a function of the concentration of a cell of an intrinsically uniform malignancy. POSITION OF THE CANCER CELL IN THE LIFE-CYCLE In accounting for the nature and origin of the single cell type comprising the constant malignant component in the varying morphological exhibitions of cancer, we find one of two alternatives open. The definitively malignant cell either has its normal counterpart in the life-cycle or the malignant cell is without a normal cellular counterpart and, therefore, arises as a spontaneous generation. Since spontaneous generation is an untenable postulate, the only alternative is that the malignant cell has its counterpart in the life-cycle. The question then arises whether this counterpart is a relatively developed cell or the most primitive cell in the life-cycle. Since the primitivity of the cancer cell is a commonplace, in looking for its cellular counterpart in the life-cycle we turn to the most primitive cell in this cycle. This is the trophoblast cell. Then as a logical corollary of the unitarian thesis, we should find the trophoblast as the constant malignant component in all exhibitions of cancer: the malignancy of the cancer varying directly with its concentration of trophoblast cells and inversely with its concentration of somatic cells. If the unitarian thesis is valid, then the most malignant exhibition of cancer possible should be comprised almost completely of frank trophoblast cells; and, in being so comprised, should epitomize the cellular and other phenomena shared by exhibitions of a lesser malignancy. The most highly malignant exhibitions of cancer known are the chorionepitheliomas comprised of frank trophoblast cells, cytologically, endocrinologically and otherwise indistinguishable from normal pregnancy trophoblast cells. If cancer is an unitarian phenomenon whose malignancy is a function of the concentration of trophoblast cells within a given tissue, then the greater the concentration of such cells within a tissue the higher the malignancy [Page 151] 2 of the tissue and the more profound its cytological deviation from the cytology normal to the tissue. If the unitarian thesis is valid, then the single exception to this generalization would comprise the most malignant of all exhibitions of cancer: that involving the pathologic exhibition of the normally or "physiologically" malignant pregnancy trophoblast. It is, therefore, most significant that when pregnancy trophoblast is malignantly exhibited as primary uterine chorionepithelioma there is no ascertainable cytological, endocrinological or other intrinsic change whatever from the normal trophoblast cell. As Boyd has phrased it, "microscopically the chorionepithelioma is an exaggeration of the condition normally found in pregnancy."23 All other tumors represent an attenuation of the condition of their normal tissue of origin. PROPERTIES OF THE TROPHOBLAST CELL But if cancer is, as an unitarian phenomenon, trophoblastic then we should expect to find occasionally in the male---where trophoblast never normally exists---at least some cases in which the failure in somatic resistance to the definitive malignant cell (trophoblast cell) is so complete that the trophoblast is frankly exhibited as such in the fiercely malignant testicular or primary extra- genital chorionepitheliomas.24, 25, 26, 27, 28 The chorionepitheliomas are unquestionably the most malignant tumors in either sex, and the degree of their malignancy is routinely determined by measuring the gonadotrophin their trophoblast cells excrete.29, 30, 31 If the trophoblast cell, presented outside the normal canalization or checks of pregnancy, is truly the cancer cell, then it must be impossible for the trophoblast cell or its hormone---"chorionic" gonadotrophin---ever to be found in the male or, aside from the canalization of normal pregnancy, in the female except in a malignant fashion. Neither the trophoblast cell nor its hormone has ever been so found except as cancer. And whenever the trophoblast cell or its hormone has been found in the male or the non-pregnant female, the associated malignancy is observed to vary directly with the urinary excretion of trophoblast cell-produced gonadotrophin. Even a superficial examination of the trophoblast cell indicates that it possesses such properties of the cancer cell as invasiveness, erosiveness, autonomy and ability to metastasize throughout the organs of the host.32, 33 Indeed, though normally canalized to physiological ends, the pregnancy trophoblast in carrying the conceptus from anatomically outside of the maternal host to implantation within the uterine wall must behave in a profoundly malignant fashion. No malignant cell invades any tissue any more rapidly and completely than the pregnancy trophoblast does the human uterus in the first few weeks of gestation. If the trophoblast cell, then, is instrinsically malignant, this malignancy should become especially apparent when the trophoblast is removed from the normal extrinsic checks and controls surrounding it in its normal canalization of pregnancy. Maximov is among those who have observed normal pregnancy trophoblast in tissue culture pari passu non-tropho- [Page 152] blast.34 He describes as follows a tissue culture preparation of a normal rabbit embryo plus the contiguous trophoblast: "From the very first moment of their formation in vitro, the trophoblastic elements, whose function under normal conditions is to destroy, resorb, and penetrate into the uterine mucosa, attack the growing embryonic tissues. They glide between cells through the intercellular spaces, along blood vessels, gnaw 3 large holes in epithelial sheets....Wherever they appear they dissolve, destroy and resorb everything surrounding them. The picture sometimes bears a striking resemblance to chorionepithelioma malignum. As in vitro there is no maternal tissue, the destructive tendencies of the trophoblast are directed toward the net and only available---the embryonic tissue itself. This is rapidly destroyed and totally used up for the nutrition and growth of the trophoblast." Maximov's description of the nutritive utilization by the trophoblast of somatic or embryonic tissue in vitro bears a striking parallelism to the following observation of Greenstein35 on the nutritive behavior of the cancer cell: "It is, indeed, astonishing that a tumor can thus attach itself to an organism already running downhill in negative nitrogen balance and subsequently grow at the host's further expense." Parasitization is eloquently clear in the description given by Maximov and it is implicit in Greenstein's observation. Normal pregnancy trophoblast represents, of course, a parasitization of cells of one genetic constitution by those of another. If cancer is an unitarian and thereby a trophoblastic phenomenon, its parasitic behavior is very easy to understand. Were pregnancy trophoblast in vivo or in situ to lack the humorally mediated checking influences that are lacking in vitro then such tissue would expectedly behave as it does in vitro and be exhibited in the fiercely malignant fashion of primary uterine chorionepithelioma. Rather than pause here to review in further detail the points of identity between the cancer cell and the trophoblast cell, of which the senior author in a review of over 17,000 papers has been able to catalogue 43, let it suffice to say that we have been unable to find a single point of dissimilarity between the cancer cell and the trophoblast cell. The points of identity, of course, are those shared exclusively by the cancer cell and the trophoblast cell and not shared by any somatic cell. THE CELL OF ORIGIN AND THE MEANS OF ITS DIFFERENTIATION If cancer is a truly unitarian phenomenon, then its cellular origin as well as its cellular nature are exemplified in the origin and nature of the most malignant exhibition of cancer---primary uterine chorionepithelioma. Pregnancy trophoblast arises through the differentiation by meiosis of a diploid totipotent cell in response to organizer stimuli (afforded through the sex steroids). The meiosis of the diploid totipotent cell results in a haploid gametogenous cell whose only alternative to death is division (sexually or parthenogenetically induced) with the consequent production of trophoblast. The only cell from which the most primitive cell in the life-cycle, the trophoblast cell, can arise is the most undifferentiated or [Page 153] most potent cell in the life cycle: the diploid totipotent cell. It is this cell alone that is competent for meiosis. In fact, aside from the explanation of spontaneous generation, only two alternatives exist for the origin of the malignant cell. Like all other growth phenomena, it may arise as the result of the differentiation of an undifferentiated cell in response to organizer stimuli; alternatively, it may be ascribed to the ontogenetic "reversion" of normal cells to a primitive state. Even though the very notion of such reversion is a thermodynamic fantasy inadmissible by modern biology, if a normal cell could revert, the most primitive cell in the life cycle toward which such reversion could occur is still the trophoblast cell. Hence, aside from the errors of spontaneous generation or cellular 4 reversion, only the phenomena of cellular differentiation are tenable in accounting for the origin of the cancer cell---though the stimulus to such differentiation may, of course, be diversely mediated. It is thus a simple embryological fact that the malignant component of the most malignant of all exhibitions of cancer---primary uterine chorionepithelioma---represents the unchecked growth of normal trophoblast that has arisen through the differentiation of a diploid totipotent cell, by reduction division, and the division of the consequent haploid gametogenous cell to produce trophoblast. We have seen the proof of this in the fiercely malignant behavior of rabbit trophoblast removed from the checking influences of the maternal host and placed in tissue culture. This trophoblast, of course, came into being through processes normal to the production of all trophoblast in normal gestation. This is true also of the trophoblast of primary uterine chorionepithelioma. It is necessary that we emphasize here the fact that our description of the origin of any trophoblast cells is merely a recapitulation of commonplace, universally accepted embryological data. We must not permit terminology to obscure this fact. Let us add that it has been experimentally established that in mammals the haploid gametogenous cell in either the male or the female may be nonsexually activated into division with the consequent and inevitable production of trophoblast. Because the trophoblast cell of primary testicular chorionepithelioma is indistinguishable from that of the normal pregnancy trophoblast cell36, 37, 38 or a trophoblast cell of primary uterine chorionepithelioma,39, 40 the general consensus in pathology that chorionepitheliomas arise from the division of a gametogenous cell (non-sexually activated), derived through the normal meiosis of a diploid totipotent cell, is biologically and logically sound. It is likewise generally recognized that primary extra-genital chorionepitheliomas occurring in both sexes represent trophoblast that shares a common cellular origin with all other trophoblast; an origin from an haploid gametogenous cell (through fertilization or non-sexually) that has arisen through the meiosis of a diploid totipotent cell. This principle is congruent with the axiom that cells which are alike arise from pre-existing cells that are alike. [Page 154] INDEX OF MALIGNANCY If cancer is an unitarian phenomenon in which all morphological exhibitions share, in varying degrees, the known malignant component of the chorionepitheliomas, then it follows (1) that the malignancy of a growth will vary directly with its concentration of trophoblast cells and inversely with its concentration of body or somatic cells; and (2) the trophoblast cells comprising a malignant lesion must possess the capacity for being morphologically masked or obscured by the tissue in which they primarily occur or to which they metastasize. Testicular chorionepitheliomas afford an interesting vantage point for the examination of these possibilities. In screening over 900 testicular cancers in the Army Institute of Pathology, Friedman and Moore (1946) reported, in part, as follows:41 "Nearly twice as many metastases which exhibited chorionepitheliomatous structures arose from primary tumors containing no chorionepithelioma as from pure chorionepitheliomas or neoplasms containing focal chorionepithelioma. While only 0.4 per cent of the primary testicular tumors were pure chorionepitheliomas and 6.4 per cent showed focal chorionepitheliomatous tissue, 27 per cent of all metastases which terminated fatally contained chorionepitheliomatous elements." (emphasis ours) 5 Thus, not only may the trophoblast, when frankly exhibited as such in the primary site, metastasize to be morphologically masked in the secondary site, but the primary trophoblast itself may be morphologically masked by the soma and be frankly exhibited only when metastases occur into tissues of relatively lower reactivity in which the trophoblast is not morphologically masked but is frankly exhibited as such. The masking of the trophoblast by the reactivity of the somatic cells is a measure of the resistance of the host: the degree to which such somatic resistance against the ectopic trophoblast fails determines the malignancy with which the trophoblast is exhibited. Thus, the greater the incidence of a chorionepitheliomatous exhibition (trophoblast) in the metastases, the greater the degree of malignancy. COMPETENT CELL AND ORGANIZER The origin of every new cell is the result of the apposition of a competent cell and an organizer stimulus. All new cells arise as the result of cellular differentiation, which is a process by which a new cell type of a higher degree of individualization and a lower degree of developmental competence is produced. There are no exceptions to this generalization---not even the cancer cell. While a differentiated cell may become plastically deformed or necrobiotic, it can never form a new cell type through any means except the forward-moving course of cellular differentiation. Cellular reversion is a thermodynamic impossibility; it has never occurred and can never occur. Water does not run uphill---not even in cancer. The cancerous cell is neither a deformed one nor a necrobiotic one. Its lethality resides in the very fact that intrinsically it is a normal cell---though its spatial and temporal relationship to the organism-as-a-whole is an abnormal one. The trophoblastic or unitarian thesis simply recognizes that: (1) the can- [Page 155] cer cell is contained within the life-cycle and (2) that it is the most primitive cell in that life-cycle. Though the diploid totipotent cells which give origin to trophoblast are known to be very abundant in the gonads, the question next arises as to their occurrence extra-genitally. Most modern pathologists 42, 43, 44, 45, 46 recognize the existence of so-called ectopic germ cells (diploid totipotent cells) and Bounoure 47 has, in an extensive monograph, recently reviewed the conclusive observational and experimental evidence for the dispersion of such cells throughout the soma. Of course, embryologically, these cells are nothing more than totally undifferentiated cells that have not, as Arey phrased it,48 participated in body building but have reserved their total potency or competency since the initial cleavage of the zygote. Cells of various degrees of undifferentiation exist within the soma as a reservoir from which tissue repair and regeneration occur. But only the totally undifferentiated cells of the soma are competent for meiosis; these cells are the diploid totipotent cells. Of course, all cells in the soma are diploid, but only those that are totally undifferentiated are totally potent or totipotent---hence competent for meiosis. That such cells exist as well as function in the soma is further proved by the occasional occurrence of primary extra- genital chorionepithelioma in the male in such regions of low tissue reactivity as the pineal gland49,50 and the anterior mediastinum.51, 52, 53, 54 The frankly exhibited trophoblast cells are correctly attributed to the only progenitor of trophoblast: a diploid totipotent cell that has undergone reduction division or meiosis to form a haploid gametogenous cell that has trophoblast formation as the only alternative to death. 6 Carcinogenesis is thus seen to be a phenomenon involving a spatially anomalous differentiation in response to organizer stimuli. (Primary uterine chorionepithelioma---as well as normal pregnancy trophoblast---while involving precisely the same differentiation in its origin does not, of course, involve it anomalously.) The differentiation involves the phenomenon of meiosis with the consequent production of trophoblast, which, presented ectopically, is inevitably exhibited as cancer---the malignancy of which depends upon the extent to which such ectopic trophoblast is resisted. Thus in the unitarian thesis we see the malignant component in all exhibitions of cancer deriving from precisely the same cell type from which the chorionepitheliomas arise. We see all producing the same cell type---trophoblast. We see this cell doing ectopically precisely what it does in its normal canalization: eroding, infiltrating, and metastasizing. "One of the most important problems in cancer research," Greenstein55 points out, "is concerned with the question of why primary tumors metastasize." If cancer is trophoblastic, the problem of metastases is resolved: the normal pregnancy trophoblast is the only cell in the life-cycle that regularly metastasizes, doing so throughout the maternal host in the early months of pregnancy.56, 57 The stimuli to malignant differentiation are exemplified in the sex steroids which induce the meiosis of diploid totipotent cells in their normal [Page 156] canalization. In view of the relatively specific organizer action of steroids, it is significant that practically all of the carcinogens are either steroids or, like diethylstilbestrol, possess the physiological properties of steroids. Though carcinogenesis may be mediated by highly diverse means, the ultimate common pathway involves the apposition of competent cell and organizer stimuli. The competent cell is always a totally undifferentiated cell (diploid totipotent cell) and the organizer stimulus ultimately involved appears to be a steroidal compound. Agents producing a chronic inflammation can also prove indirectly carcinogenic, since chronic inflammatory sites have a marked capacity for localizing or concentrating steroidal sex hormones as well as other substances.58 Certain chemicals may also prove indirectly carcinogenic through impairing the somatic detoxification mechanism for steroids.59, 60 That under special and very limited circumstances viruses may also contribute to the common pathway by which malignant differentiation is accomplished in birds* and rodents is recognized. Virchow, however, pointed out 90 years ago that no stimulus can elicit from a tissue potencies not inherent within the tissue. The general consensus is that the role of the cancer virus is evocatory, eliciting from the organism an inherent potency; rather than creative, conferring de novo the cancer cell upon the organism. ESTROGENS Since the meiosis of normally canalized diploid totipotent cells is accomplished in both sexes through the organizer action of steroidal sex hormones, a review of the formidable literature on the carcinogenic properties of estrogen correlated with the unitarian thesis would be most pertinent to a complete elucidation of the thesis. Space will not permit this, and it must suffice to say that the normal estrogens bear as crucially a basic relationship to the origin of malignant cells, under ordinary circumstances, as chorionepithelioma bears to their cellular identity. 7 VIRUSES AND SOMATIC MUTATION Since the virus theory is subsumed under the unitarian thesis---as a specialized contributory means** of eliciting the malignant differentiation---the chief remaining theory is the somatic mutation hypothesis. This hypothesis explains nothing and is, in fact little more than a circular definition: cancer is due to a change; a change is a mutation. This change occurs in the body or soma; therefore, cancer is due to a somatic mutation. On the other hand, the trophoblastic or unitarian thesis does embrace a very definite genetic "mutation." This "mutation" is expressed as meiosis ------- * The phylogenic homologue of the trophoblast (extra-embryonic blastoderm) in birds is known to exhibit, under certain conditions, malignant properties: e.g., anidian formation61. **Joseph Needham62 has cogently remarked: "It is an instructive exercise to read through the writings on the virus theory of cancer, substituting the words 'active agent' or 'active extract' for virus wherever it occurs. The results are illuminating." [Page 157] whereby, with the division of the consequent gametogenous cell, the ectopic trophoblast (cancer) cell presented to the soma is, through the necessity of meiosis, of a genetic composition unique from the soma; and, therefore, in the most literal genetic sense a neoplasm. Even were one uncritically to accept the somatic mutation hypothesis63 or the virus theory of cancer,64 it would be necessary either to seek their resolution in the unitarian or trophoblastic thesis or to turn to a non-unitarian explanation. In which case it would be necessary, then, to postulate an indefinitely large variety of unknown cancer viruses or a similar variety of unknown somatic mutations to account for the origin of the cancer cell. But not even these would suffice since neither hypothesis could account for the fiercely malignant behavior of normal trophoblast in vitro---nor for the fact that this cell has never been found in a non-pregnant organism except as cancer. MEIOSIS We have observed that the extra-genital dispersion of diploid totipotent cells is a commonplace fact. We have specifically ascribed the origin of all morphological exhibitions of cancer to the meiosis of one or more such diploid totipotent cells with the consequent production of a gametogenous cell whose only alternative to death is division with the resulting production of trophoblast. In the normal reproductive canalization the only way in which trophoblast can arise is through the meiosis of a diploid totipotent cell and the consequent division (non-sexually or by fertilization) of the resulting gametogenous cell to produce trophoblast. Therefore, one question alone remains here: can the same diploid totipotent cell in an extragenital site undergo meiosis to eventuate in trophoblast production? As early as 1879 Arnold observed gametoid (meiotic) mitosis in malignant tissue. About twenty years later Farmer, Moore and Walker reported the occurrence of meiosis (heterotypic mitosis) at the border of malignant tumors.65 In 1929 Evans and Swezy described in inflamed somatic tissue changes "strikingly similar to those of meiotic mitosis."66 In 1936 Hearne observed meiotic changes 8