THE 
Treatment of Epithelioma 
with Mild Caustics. 
BY 1 
DANIEL LEW re, M. D. 
SURGEON TO THE NEW YORK SKIN AND CANCER 
HOSPITAL. 
Read before the 
New York Dermatological Society. [Read before the New York Dermatological Society.] 
THE TREATMENT OF EPITHELIOMA 
WITH MILD CAUSTICS. 
BY 
DANIEL LEWIS. M. D. 
SURGEON TO THE NEW YORK SKIN AND CANCER HOSI’I TAU 
STATISTICS from the London Cancer Hospital 
from 1851 to 1872, show that of 8,579 cases of 
cancer, 2,010, or more than twenty-five per cent., 
were surface epitheliomata. 
Next to-scirrhus tumors then come these cases, 
which, whether properly or not, have been con- 
sidered within the field of dermatology. Although 
what 1 shall claim to be the effect of mild caustic 
application applies with greater force to the more 
malignant varieties, such as epithelioma of the 
tongue, rectum and cervix uteri, it is to those 
directly affecting the skin to which attention is 
directed in this paper. 
It is well to consider briefly some of the characters 
belonging to this group. The majority of patients 
are men, and in most cases the disease is located in 
some portion of the face, the side of the nose, on a 
level with the angle of the eye being so frequently 
affected as to be almost justly termed the point of 2 
TREATMENT OF EPITHELIOMA 
selection for these cases. The disease seldom begins 
until middle age has been passed, when the vital 
forces are declining, and some local irritation is often 
the exciting cause in this locality, as is almost in- 
variably the case in cancer of the lips. During the 
past year I have treated one which developed in the 
callosity resulting from the pressure or raiher pinch- 
ing of eye-glasses, and also another epithelioma occur- 
ring on the dorsum of the nose, where an old-fash- 
ioned spectacle bow had rested for many years. 
The disease spreads in the direction where it 
meets the least resistance, that usually being in the 
skin only, the underlying tissues becoming very 
slowly affected. Even the eyeball often resists the 
disease until both the lower and the upper lids have 
been destroyed. The natural course of the disease 
is exceedingly slow except in those parts composed 
of loose, non-resisting tissues, such as the lip, vulva, 
penis and scrotum. 
Virchow says of it that “ it remains for a long 
time local, so that the nearest lymphatic glands 
often do not become affected until after the lapse of 
years, and then again the process is for a long 
time confined to the disease of the lymphatic 
glands, so that a general outbreak of the disease 
in all parts of the body does not take place until 
late, and only in rare instances.” WITH MILD CAUSTICS. 
3 
The photograph of the patient, I here present, 
shows the progress of the disease in seventeen years, 
without any medical or surgical interference whatever, 
which is the most remarkable part of his history to me, 
for we very seldom see a case of cancer for which 
something has not been ordered by a physician, or 
some better qualified person, to promote a cure. 
In comparing the characters just enumerated with 
those of cancer of other organs than the skin, it 
becomes apparent that these superficial, slowly in- 4 
TREATMENT OF EPITHELIOMA 
fectious, and I might add nearly painless affections, 
are naturally the most curable of all the cancerous 
diseases. I say naturally the most curable, because, 
as we find these cases in practice, they are very often 
deep in surrounding tissues, rapidly infecting neigh- 
boring lymphatic glands, giving rise to considerable 
pain, and rapidly advancing to a fatal termination, 
and all this the result, as 1 believe, of the mild 
cauterization which is employed in nearly every 
instance in the early history of the case 
By the term mild cauterization, I mean all caustic 
applications of whatever kind which aim at a 
gradiial destruction of the diseased tissue A few 
cases will illustrate my meaning. A young man 
of thirty years consulted a physician about one 
year ago for -a “cracked ” lip which had troubled 
him two or three months. During the next six 
months eighty applications were made to the lip, 
so the patient says, of a caustic answering to the 
description of nitrate of silver. The result is the 
entire lower lip cancerous, an enormous tumor on 
the left side of the face and inferior maxillary 
region, which has ulcerated in several places, and 
the <k cancer cachexia ” of the older writers indicates 
an early fatal termination. This very unusual 
glandular infection can only be accounted for by the 
fact, as I believe, that the repeated applications WITH MII.I) CAUSTICS. 
5 
acted in the same manner as the local irritation 
which is so often the exciting cause of the primary 
disease. 
An old lady, who was under my care while I was 
connected with Dr. Hulkley's service at the Skin 
and Cancer Hospital, suffered from an epithelioma 
of the ala nasi on the right side, and a small one on 
the cheek of the opposite side. The latter was 
thoroughly removed by curetting, after which a strong 
pyrogallic acid ointment (3 iv— 3 i) was applied 
for three days and the ulcer healed without delay 
and never recurred. The curetting removed all the 
the disease, and the ointment,.acting as a stimulant 
to the surrounding blood supply, actually hastened 
the granulation process. 
The larger epithelioma on the nose was curetted, 
the ointment applied and the disease sprung up 
anew. The strength of the ointment was increased 
until the pure acid was several times applied, and 
finally, after months of the most faithful trial of the 
plan I ever witnessed, the case was treated surgi- 
cally and a prompt cure rapidly effected. 
In this latter instance all the disease was not re- 
moved by the curette, and the mild caustic applica- 
tion stimulated the growth of the remaining cancer 
elements. 
In a large number of cases which I have observed, 6 
TREATMENT OF EPITHELIOMA 
where the pyrogallol was used, the same unsatisfac- 
tory results followed, so that, in my judgment, it 
can only be useful in those semi-malignant ulcers of 
the skin which have no elevated or indurated bor- 
ders, while in the ordinary epitheliomata its use is 
not alone useless but positively injurious. 
The successes with pyrogallol and resorcin are so 
exceptional that their use in such cases should be 
discarded altogether. 
Nitrate of silver is one of the most frequent of 
mild applications and also one of the most injurious. 
It is probable that no epithelioma of the tongue 
ever escaped an application of this remedy, and it is 
equally certain that no case was ever benefited 
thereby. 
Without multiplying instances of such meddle- 
some treatment, let us consider the effects of such 
applications upon the healthy skin. The epidermal 
layers are promptly destroyed ; but as they contain 
no power to carry diseased cells into surrounding 
tissues, their safety or destruction does not concern 
us now. The changes in the true skin are those 
belonging to simple inflammation, viz.; hyperaemia 
with engorgements of the affected parts with blood, 
swelling, redness, pain, often oedema resulting from 
stasis in the vessels, and increased activity in the 
tissues, with tendency to new products. WITH MILD CAUSTICS. 
It cannot be doubted that the blood vessels and 
lymphatics are absolutely essential to a healthy 
propagation, if 1 may use the term, of the cancer 
elements in the skin as elsewhere in the body. In 
the case represented by the photograph, oedema of 
the upper lid caused by the destruction of its blood 
supply at the angles of the eye, was an insurmount- 
able barrier to the progress of the disease in that 
direction for many years. 
Given an area of skin infiltrated with malignant 
disease, and then stimulate all the activities of adja- 
cent tissues, and only one result can follow—-a 
greater degree of activity to the diseased area. This 
brings us to the laying down of this proposition, 
justified by experience as well as philosophy: 
No mild caustic application should ever be made to 
any cancerous surface under any circumstances. 
Only such caustics are admissible as completely 
and rapidly destroy the diseased tissues ; such reme- 
dies destroy the vessels and lymphatics adjoining 
and so prevent dissemination of cancer elements. 
An exception should possibly be made in favor of 
one mild remedy, the galvanic current. 
Julius Althaus recommended its use in a paper 
published in 1869, and several writers have since ad- 
vised its use in these cases, prominent among whom 
was the late Dr. Heard of this city. It is not as a 8 
TREATMENT OE EPITHELIOMA 
caustic, however, but by the chemical action of the 
negative pole, attached to a five-celled battery, that 
a marked change in the diseased tissue has been af- 
fected which terminated in complete cure in several 
instances. My own experience is too limited to 
enable me to express an opinion, but a few applica- 
tions, made by Dr. Fox in a lower lip which was ex- 
tensively diseased, caused a very decided softening 
and shrinking of the growth. The case is an incur- 
able one, or I w.ould insist upon a very thorough 
trial of the remedy.