The Caustic Treatment of Cancer BY DANIEL LEWIS, M.D. SURGEON TO THE NEW YORK SKIN AND CANCER HOSPITAL Reprinted from the Medical Record, February 13, 1892 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1892 The Caustic Treatment of Cancer BY DANIEL LEWIS, M.D. SURGEON TO THE NEW YORK SKIN AND CANCER HOSPITAL Reprinted from the Medical Record, February 13, 1892 NEW YORK TROW DIRECTORY, PRINTING AND BOOKBINDING CO 201-213 East Twelfth Street 1892 THE CAUSTIC TREATMENT OF CANCER.1 It is possible that pathological research may yet result in the discovery of an internal remedy lor cancer, but an existing malignant tumor can never be entirely removed from living tissue without some active intervention by the physician or surgeon. We lay down the axiom, then, that cancer must not only be destroyed before a cure can be effected, but also in some way removed from the body to insure continued immunity from the disease. Removal may be accomplished by operation or by escharotics. Up to the present time the tendency of the profession has been toward the surgical operation, to the exclusion of all other remedies which we have been pleased to denominate " quack remedies." The truth of the matter is, that the surgeon who con- demns the caustic treatment in toto is just as irrational in his judgment as the cancer quack who declares that all cancer can be cured without the knife, and by a painless process. Both parties are in error, and it is my purpose briefly to indicate the cases which are suitable for caus- tic treatment, and to describe the means employed. This paper is based upon three hundred cases occurring in my service in the New York Skin and Cancer Hospi- tal and in private practice. In this report no record is made of the treatment by mild cauterization, which I have heretofore condemned in a paper read before the New York Dermatological Society, and given what appeared to me a justification of 1 Read before the Medical Society of the County of New York, January 23, 1892. 4 the position. Among those which may be termed mild caustics are nitrate of silver, carbolic acid, pyrogallic acid, resorcin, and that South American extract of some- thing which is called alveloz. None of the remedies of this class are true escharotics, but rather irritants. All fall far short of the one great requirement of a proper escharotic for cancer, viz., an agent which will produce rapid as well as complete destruction of the diseased tis- sue. All are liable to stimulate absorbents and so pro- mote dissemination of the disease, and the only safe em- ployment of them consists in discarding them altogether. For the purpose of this discussion the following di- vision of cancer may be adopted : i. Cancer of the breast (including carcinoma and sarcoma) ; tumors of the axil- lary and cervical glands; cancer of the vulva, of the testis, of the penis, and of the rectum. 2. Cancer of the cervical portion of the uterus, of the tongue, and of the tonsil. 3. Cutaneous cancer, including cancer of the lip and of the external ear. All malignant diseases not included under these three heads are outside the province of this paper, as no advo- cate of treatment by caustics, however ardent his prefer- ences, has ever attempted to employ such means in the treatment of disease of internal organs, of bone, of the thyroid gland, or even of the larynx or vagina, without regretting it afterward. Before considering these classes in detail, it may be stated that no method of treatment should be employed which aims at anything short of complete destruction and removal of diseased tissue. The only possible ex- ceptions to this rule are occasional instances in which a tongue may be removed to allow of increased facility in feeding, a tumor near the eye where the sight maybe pre- served, or where a pendulous or ulcerating tumor (as of the breast) may be rendered less painful or offensive for the time being by the removal of a portion of it. Such are palliative measures which may be justifiable, although life is not usually prolonged thereby. 5 The treatment of cancer of breast by caustics has often been recommended, even by physicians of good repute, while the cancer quack has, almost from time immemo- rial, secured both fortune and glowing testimonials of merit from this unfortunate class of patients. If the his- tory of removal by operation of recurrent disease in my service at the hospital in such cases could be published, with the original testimonials of cure without the knife, it would prove an effective antidote for such insinuating and dangerous pretensions. I hazard the statement that no cancerous tumor of the mammary gland ever existed which was a proper case for the employment of caustic treatment. I do not deny that the tumor can be de- stroyed and removed by such applications as Marsden's paste, or Bougard's or Michel's paste (I have employed these means successfully), but the process requires sev- eral months, is painful in the extreme, crude in its exe- cution, and, worse than all else, tends directly, through the chronic irritation of adjoining tissues, to disseminate the disease to other organs. Of the very small propor- tion where a cure has finally resulted from these proced- ures, a much more rapid and satisfactory result would have been secured by a surgical operation. No cancer of the breast should ever be treated without removing every lymphatic gland in the axilla of the side affected, and this cannot be accomplished by a plaster or a caustic -of any description. Mr. Charles Egerton Jennings, of London, in his ad- mirable book on "Cancer and Its Complications," in speaking of cancer of the breast, uses these words : " When caustics are employed to destroy a cancerous growth of any considerable dimensions the results are far inferior to excision or amputation under modern con- ditions. The bulk of the growth is hardly ever eradi- cated, and manifest local recurrence occurs ordinarily after the lapse of a few weeks. The caustics are applied and reapplied, and this sad treatment goes on until the patient is relieved by death of a treatment which adds 6 pain to that of the disease, which it ordinarily aggra- vates." He makes an exception in favor of caustics in certain very old and debilitated patients, where there is an open ulcer, with the surrounding tissues adherent to the ribs, for the purpose of arresting offensive discharges for a while, and ends by recommending a preparation consist- ing of . Hydrochlorate of cocaine 2 grammes. Caustic potash 6 " Vaseline 8 " After the skin is well cleansed, small portions of this paste are well rubbed in with a wooden spatula, and in a few minutes considerable tissue can be destroyed. It is not a painful application, and I have removed small growths on various parts of the body quite satisfactorily. The charred portions should be carefully wiped away with absorbent cotton during the application, to prevent destruction of adjoining healthy tissues. Whatever arguments can be urged against caustics in breast cancer apply with increased force to disease in the axillary glands. The cicatrix resulting from such treatment resembles that of an ordinary burn, and not long since a patient applied to me after a tumor of the axilla had been removed by a celebrated " dealer in knifeles? operations," and the contraction had firmly bound the arm to the side. I may add that the disease recurred in the cicatrix. In the glands of the neck there is the added danger of destroying important organs, for only great familiarity with any caustic can enable us to predict the extent of its action to the requisite degree for the safety of the jugular vein or the facial artery. The instances of this class where caustics have been employed that have come under my notice are sad beyond description, and the only word to add concerning caustics in tumors of the neck is 7 the most sweeping condemnation. The same may be said of tumors of the testis, which are likely to be can- cerous and of rapid growth. A small superficial tumor of the vulva may sometimes be removed by electrolysis or the Paquelin cautery, but my own experience and observation in these cases compel me to state that recurrence is usually rapid and certain, and the only reasonable hope of cure lies in an early and free excision. No time should be lost in the attempt to cure with caustics. Dr. C. W. Allen recently presented to the New York Dermatological Society a patient with epithelioma of the glans penis where Bougard's paste had been employed successfully, but the corpus spongiosum is so excessively prone to infiltration with cancer that amputation as near the pubis as possible appears the safer procedure. A radical cure of the penis by operation is not unusual, pro- vided treatment is undertaken early in the progress of the disease. The caustic paste may be considered admissible pro- vided the disease is confined to a small portion of the foreskin, if indeed that condition is ever met with in practice. Of our second class-cancer of the cervical portion of the uterus, of the tongue and the tonsil-it will be noted that they are in a class by themselves, because the plasters, pastes, etc., cannot be used without pois- oning the patient, and some form of the actual cautery is the only proper escharotic, should any be deemed ad- visable. In regard to the cervix there is so much to be said that the limits of this paper forbid a thorough discussion of the subject. I believe, however, that of the considerable number of cases which I have observed in my own and my colleagues' practice, all are now dead with one excep- tion, and she is not likely to long continue to break this dismal record of mortality. Many have been curetted thoroughly and afterward cauterized, and some arrests of 8 symptoms secured, but all improvement was only tempo- rary. Mr. John Williams gives his cases in admirable de- tail, and high amputation was no more satisfactory. Ex- tirpation. in the cases where the woman survives the shock, is sometimes followed by recurrence in the peri-uterine cellular tissue, so that we are forced to the conclusion that cancer of the uterus is one of the most incurable of all the malignant diseases. The spongy character of the tongue accounts for the extreme malignancy of disease therein and its conse- quent incurability. Even the actual cautery is useless, and whether you amputate by Whitehead's or Kocher's method, or any other, a year of immunity is longer than I have ever secured, although Butlin reports six cases out of a total of seventy who remained cured after three years. It may be said, in brief, concerning epithelioma of the tonsil (primary), that the removal thereof by cautery in- volves great danger from secondary hemorrhage, while primary hemorrhage is very liable to cause death when removal by operation is attempted, so that the only favor- able comment to be made upon these cases is the extreme rarity of the disease, the entire number of recorded cases being less than one hundred. Concerning the third class, which comprises all cuta- neous cancer, epithelioma of the lips and of the external ear, it may be said that they are the most curable of all varieties of cancer, and in this respect stand in sharp con- trast with the class just considered. There is no reason why ninety-five per cent, should not be absolutely cured, if treated at the earliest period in the course of the dis- ease. There need be no hesitation in giving the patient himself this prognosis, provided always that he will per- mit very frequent observation and prompt destruction of any epithelial growth. Cutaneous cancer is usually treated more satisfactorily by escharotics than by any other method, and for various reasons. The patients are usually past middle age, and 9 often far advanced in years, and, as a class, not good sub- jects for etherization. The antipathy to a surgical oper- ation often leads them to delay treatment until the pre- cancerous stage, as Mr. Jonathan Hutchinson has termed it, has been followed by one of active malignancy. You can always quite readily persuade them to have a plaster applied. The disease can be thoroughly destroyed by the caustic plasters, for they will all act sufficiently upon dis- eased tissue in so much less time than upon healthy skin that there is almost an excuse for the fallacy that they exercise a positive power of selection. The resulting cicatrix, when the deep subcutaneous tissues are not in- volved, is a very smooth, white, and in every way healthy one, far less conspicuous than after operation. The only cases in which an operation should be preferred to a caustic are those involving the mucous surface of the lip, the eyelids, and all others which have involved a large surface, so that dangerous poisoning might result from absorption. The choice of a proper escharotic is of considerable importance. If the disease be a very small warty growth, the potassa and cocaine paste of Mr. Jennings is a good one. Acetic acid must be at hand to limit its action as soon as desired. Where the disease is that form of epi- thelioma called rodent ulcer by some, and Jacob's ulcer by other authors, with little or no induration of the borders, a paste composed of lactic acid and silicic acid, in such proportions as to make a thick paste, is effectual in destroying the diseased surface. It has one advantage over others in that it is not poisonous, and can be spread over a large surface. It is less active than the others, and requires frequent repetition. I now very seldom employ it. The actual cautery is too painful, and patients are much frightened by the very appearance of the doctor armed with a red-hot instrument. In 1874, in a paper before this Society, I described the method, then new, of applying an arsenical paste as rec- ommended b.y Dr. Alexander Marsden, Surgeon-in-Chief 10 of the London Cancer Hospital, and gave histories of 12 cases successfully treated by it. Since that time I have employed the same paste in over 100 cases. It is satisfactory in the main, and has become a well-recog- nized remedy throughout this country. In some cases the reaction is very great and the pain very severe, al- though less pain is experienced if cocaine is mixed with it. It is composed of arsenious paste, two parts ; muci- lage of acacia, one part; mix into a paste too thick to run. It is then applied to only one square inch of the ulcer, covered with cotton to absorb any superfluous paste, and left on until swelling occurs around it, with heat and redness, when it is removed and aline of demar- cation usually surrounds the surface cauterized. From one to three days are required to produce the desired effect. , Warm poultices are then applied until the slough separates (usually about a week), when, if the disease is all removed, the healing process proceeds as in an ordi- nary granulating sore. The same process is to be repeated until the disease is all removed. Marsden insists that no cancer of more than four inches in extent should be thus treated, and only one square inch at a time, and the case very carefully watched. The surgeons of the London Hospital inform me that even Marsden himself seldom employs the paste. They have substituted an application called Bougard's paste, after the Belgian surgeon who first published the formula in his work on caustics. This author brought it forward as a cure for mammary cancer, but as such, in my judgment, it is open to the same ob- jection as all other caustics; but in cutaneous and lip cases, in fact all surface epitheliomata, where any escharotic is admissible, this is by all odds the best we have at present. It is less painful than Marsden's, forms a more dry and friable slough, can be safely applied to a larger surface, and can always be prepared and ready for instant use, for in a covered jar it will keep for many months. With both pastes the surface must be denuded, if necessary, by caustic potash to render the action prompt and effective 11 in the shortest possible time. Bougard's formula is as follows : Wheat flour 60 grammes. Starch 60 " Arsenic 1 " Cinnabar 5 " Sal ammonia 5 " Corrosive sublimate 0.50 centigramme. Solution of chloride of zinc at 52 .. 245 grammes. The first six substances are separately ground and re- duced to fine powder. They are then mixed in a mortar of glass or china, and the solution of chloride .of zinc is slowly poured in while the contents are kept rapidly moved with the pestle so that no lumps shall be formed. A thick layer of this is spread on cotton and left in posi- tion twenty-four hours, and then managed in every way as Marsden's paste. Few cases require a second application. The ulcer may be dressed with balsam of Peru ointment of varying strengths, according to the stimulation re- quired, and all exuberant granulations are to be kept in check by the usual methods. An excellent dressing, in- stead of the Peiuvian balsam, is a five or ten per cent, aristol ointment, with vaseline as a base. However, this after-treatment is not of vital importance except in one respect, viz., healing under a scab in cancer cases can never be trusted. 249 Madison Avbnue.