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 Dr. William S. Stone 
 
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A REVIEW OF THE HISTORY 
 OF CHEMICAL THERAPY IN 
 CANCER. 
 
 BY 
 
 WILLIAM S. STONE, M.D. 
 
 NEW TORK. 
 
 REPRINTEI> FEOM 
 THE 
 
 MEDICAL RECORD 
 
 October 7, 1916. 
 
 WILLIAM WOOD & COMPANY 
 
 NEW YORK. 
 
A REVIEW OF THE HISTORY OF CHEMICAL 
 THERAPY IN CANCER. 
 
 By WILLIAM S. STONE, M.D., 
 NBW YORK. 
 
 The presentation of a method of cancer therapy 
 other than operation with the knife has usually 
 been conceived either in ignorance or in the hope 
 of financial gain. In the case of the chemical 
 caustics, unfortunately for progress in the treat- 
 ment of the disease, the unqualified condemnation 
 of the manner of their exploitation has repeatedly 
 prevented educated surgeons from learning how to 
 use them and excluded a scientific study of their 
 possible efficiency. 
 
 It is a remarkable fact that, so far as "cancer 
 cures" relate to the local treatment of the disease, 
 they have almost invariably been found to consist 
 of arsenic, zinc, or the alkaline caustics. Arsenic 
 is known to have been the effective ingredient of 
 the applications made to cancerous tumors by the 
 Indians, Egyptians, and Persians, and a salve, 
 designated as Unguentum Egypticum, consisting 
 of arsenic and vinegar, was in general use until 
 the middle of the fourteenth century, when two 
 notable surgeons of the University of Avignon, 
 Henri de Mondeville and Guy de Chauliac, made ef- 
 
 Copyright, William Wood & Company. 
 1 
 
forts to improve the methods of diagnosis and 
 treatment. Prior to this period it is clear that all 
 classes of people — physicians, scholars, mendicant 
 friars, and old women — treated all kinds of tumors 
 with escharotic pastes and solutions, the most ef- 
 fective of which contained arsenic. The most skill- 
 ful applications were undoubtedly made by the 
 friars. The Hippocratic theory of the nature of 
 cancer, "the atra bills," was recognized in all thera- 
 peutic efforts, but exerted little influence on the 
 methods of treatment. Diagnostic error, as a factor 
 in the determination of successful results, applied 
 alike to the use of the knife and to caustics. While 
 Galen and others of the Greek school supported this 
 theory, two kinds of growth were differentiated: 
 
 (1) the so-called scirrhus, which evidently included 
 both benign tumors and the hard, slowly growing, 
 and more definitely localized malignant growths; 
 
 (2) those growths which were plainly evident to 
 both patients and physicians as the more rapidly 
 growing and destructive neoplasms. It is probable 
 that chemical caustics were more generally used 
 than either the knife or the heated iron, especially 
 with the ulcerating grov^ths. 
 
 Guy de Chauliac (1368), a great writer on 
 surgery, as well as a skillful operator, directed at- 
 tention to the use of caustics as an adjuvant to the 
 use of the knife. He used arsenic mixed with clay 
 and noted no toxic symptoms from its employment. 
 Ambroise Pare (1510-1590), by his development of 
 the use of ligatures and sutures, created a fresh 
 enthusiasm for the use of the knife in the treatment 
 of cancer, and, although using mild salves and solu- 
 tions on ulcerating growths, tried to discredit the 
 use of arsenic because of the baleful effects of its 
 indiscriminate application. In Germany, Fabricius 
 
 2 
 
Hildanus (1560-1634), who was known as a skillful 
 operator, and is reported to have excised the axil- 
 lary glands in amputation of the breast, also tried 
 to discredit the use of arsenic. We find, however, 
 little evidence during the succeeding centuries that 
 surgery profited much by the possibilities which 
 the work of Pare and Fabricius had indicated. 
 Clowes, physician to Queen Elizabeth, advocated as 
 an additional therapeutic procedure the laying on 
 of the Queen's hand. In Germany, theories regard- 
 ing the nature of cancer simply became more nu- 
 merous, and under the designation of "systems" 
 their chief practical achievement was the exploita- 
 tion of a constitutional cure in the form of conium 
 maculatum by a Dr. Storck of Vienna, in 1761, an 
 account of which eleven years later extolled its 
 merits and the discoverer in terms of the highest 
 praise. In 1779 a society in Bantzen offered a prize 
 of 30 ducats for a cure of cancer without the use of 
 the knife, mercury, cicuta, stramonium, belladonna, 
 napello, and aconite, but there is no record of any 
 award of the prize. In France the efforts to apply 
 the recent discoveries in chemistry to the study of 
 the nature of cancer had elicited the fact that 
 tumors arise from the same tissue in which they 
 appear. In 1773 Bernard Peyrilhe, in a thesis 
 offered for the prize question by the Academy of 
 Lyons, "Qu*est-ce le cancer," presented a scientific 
 interpretation of the subject, and is credited with 
 being the first to make use of animal experimenta- 
 tion in the study of the disease. The dog, however, 
 into whose back the cancerous material had been 
 injected, howled so continuously from the resulting 
 lesion that its keeper removed him from the field 
 of Peyrilhe's observations. In regard to treatment, 
 he recommended for cancer of the breast the re- 
 
 3 
 
moval of the breast, excision of the axillary glands, 
 and the removal of the pectoralis major muscle. 
 For the treatment of nasal cancer he advocated the 
 use of the recently discovered "kohlsaure." 
 
 The beginning of the nineteenth century was 
 marked by efforts to overthrow ancient philosophy 
 and medieval empiricism, and a new era in the con- 
 ception and treatment of cancer appeared through 
 the English and French anatomical researches. 
 While John Hunter's (1786) lymphatic theory domi- 
 nated the minds of the majority of the great sur- 
 geons, it included a new conception of cancerous 
 growths as being the result of some vital activity 
 on the part of normal tissues and subject to the 
 same laws of life, growth and nourishment as the 
 normal organism. In London (1771) the Middle- 
 sex Hospital had established a special ward for 
 cancer patients, and in 1802 a committee of London 
 surgeons was formed for the investigation of the 
 nature and cure of cancer. During the three years 
 of its existence its chief attainment was the dis- 
 tribution to the medical profession in England of 
 an elaborate questionnaire, the result of which was 
 as futile as it probably would be to-day if a similar 
 method was pursued. Among the practical sur- 
 geons there were two factions regarding the theory 
 of cancer — the "localists" and the "constitutional- 
 ists." The latter did not hold to a specific theory, 
 but their ranks were largely derived from the ortho- 
 dox surgeons of the day who had been so uniformly 
 disappointed with the results of their operative 
 work. 
 
 A publication by Young in London appeared in 
 1805 on cancer and the use of chemical caustics in 
 its treatment, in which a remarkably clear summary 
 is given of the fallacious arguments of those who 
 
maintained that cancer has a specific virus, is con- 
 tagious or hereditary, and its action constitutional. 
 His own conception of cancer presents with aston- 
 ishing accuracy the present views of scientific men. 
 "Morbid and natural structures, having the same 
 principle necessary to each and governing both," 
 he says, "a morbid alteration should never be 
 viewed independently of the natural organization 
 and functions of the part, or as beyond the laws of 
 life." Briefly summarized, he considers cancer as a 
 growth arising from acquired actions about a local 
 structure that has been altered by injury or disease. 
 On the recurrence of cancer, he says: "It must be 
 obvious that the disease arises from such small be- 
 ginnings, unfortunately, that it can never be de- 
 tected until the obstruction has made considerable 
 progress ; and, as no specific virus is with it so as to 
 offer any peculiar evidence from which one might 
 take alarm, the disease thus proceeds securely in 
 the minute parts of structure until such a circle of 
 alteration is acquired as to make the change evident 
 to the touch ; so that when a surgeon takes out such 
 a scirrhus tumor it is impossible to act beyond 
 the reach of his perceptions, and to discover 
 changes which can only be imagined, which may be 
 there, or may not. . . . It is impossible to as- 
 certain the distinct line between health and disease, 
 and . . . some portions may be left, from 
 which . . . the disease may ultimately recur." 
 Based upon this conception of the disease. Young 
 directed the attention of the educated physician to 
 the advantages which he believed the chemical 
 caustics possessed if they were more discriminately 
 and skillfully applied. He says: "It must be very 
 evident to the most sanguine expectations that this 
 disease, although the treatment of it in the future 
 
may be greatly improved, must still, in many in- 
 stances, fall short of all possitility of cure. But 
 . . . are we to relax in effort because effort is 
 more required? Shall we withhold what can be 
 done, merely because all that we wish cannot be 
 done? Such, however, seems to have been the des- 
 perate sentiment in which science has left the dis- 
 ease almost to itself. It appears to have been con- 
 sidered as a thing so deeply rooted in its own sin 
 and wickedness as to be beyond reprieve — a hard- 
 ened malefactor, denied every consolation but that 
 of the knife. This negligence on the part of sci- 
 ence has given proportionate scope to the invention 
 of the quacks: they have seized upon the arms the 
 regulars threw away, and have certainly played no 
 unsuccessful part. Even old women, enlisted under 
 the banners that were deserted, have proved at least 
 (as far as their knowledge of the question went) 
 that there is just as much orthodoxy in a piece of 
 caustic as in a piece of iron." 
 
 As illustrating the attitude of the regular sur- 
 geon at that time toward the use of caustics. Young 
 narrated the story of a published correspondence 
 between two surgeons of the time. A regular sur- 
 geon, Mr. Guy, had purchased a nostrum, known as 
 the 'Tlunket remedy," which he had been using 
 extensively and apparently successfully without dis- 
 closing its composition, but claiming it had none of 
 the qualities of a caustic. The surgeon to the King, 
 Mr. Gataker, who, it afterward was ascertained, 
 had also been using a caustic without the same suc- 
 cess as had his colleague, publicly and vehemently 
 denounced Mr. Guy because he was using a secret 
 remedy. The efficient ingredient of the "Plunket 
 remedy" was eventually ascertained to be arsenic. 
 Young says: "Thus posterity seems equally obliged 
 
to these two gentlemen; to the one for condemning 
 a thing which it is very evident he was totally 
 ignorant; and to the other for the warm support 
 of what it is equally clear he did not understand, 
 or (which would seem still less innocent) of what 
 he did not choose to understand." Young indicates 
 that a more general use of caustics became intro- 
 duced from this remedy, w^hich considering the un- 
 qualified and indiscriminating way in which they 
 were applied, were attended with more success, he 
 says, than could have been looked for. 
 
 Young conceived that the advantage gained by 
 the proper use of caustics was derived from their 
 power of exciting newly formed tissues into an ac- 
 tivity beyond their power, which is always less than 
 normal structures. For this purpose he considered 
 arsenic as particularly well suited because its action 
 extended to all of the tumor tissue without rapidly 
 producing a superficial eschar, the formation of 
 which prevents the extension of the action to the 
 deeper parts. An old preparation, known as Magnes 
 Arsenicales, which he regarded as most efficacious, 
 consisted of equal parts of antimony, sulphur, and 
 arsenic, the antimony, he believed, adding to the 
 extent of the area affected. Young urged the im- 
 portance of applying treatment during the early 
 stages of the disease, and, in order to avoid con- 
 cealment of these tumors until it is too late, he 
 writes as follow^: "So long as the extirpation of 
 scirrhi of the breast is performed by the knife, so 
 long shall we have the disease fostered in secret, 
 and, in too many instances, procrastinated beyond 
 the point of safety, through the dread of an opera- 
 tion that is inevitably dreadful. For the operator 
 may argue until doomsday ere he shall persuade his 
 patient that cutting the breast with the knife is a 
 
mere nothing. . . . This rhetoric never gained a 
 jot on the fears of ignorance, or on the quick feel- 
 ings of diseased deUcacy. The truth is that, when 
 the operation is submitted to, the mind is seldom 
 made up to it but as a last resort — seldomer from 
 the convictions of reason, and never from an abso- 
 lute command over the natural terrors of the 
 heart." 
 
 There is no reason to doubt that Young's pres- 
 entation of the subject had a favorable effect on 
 the professional mind in both England and France. 
 He was a graduate of the Middlesex Hospital, and, 
 although not a member of the staff of that institu- 
 tion, he was a protege of Mr. Brodbeck, who made 
 the first financial contribution to the establishment 
 of its cancer ward. He became better known by a 
 publication in 1815 on the treatment of cancer by 
 compression, a method which received wide atten- 
 tion for many years. Recamier was enthusiastic 
 about its efficacy, and devoted two volumes to a dis- 
 cussion of its principles and technical application. 
 
 From the beginning of the nineteenth century we 
 find that all of the noted surgeons felt the need of 
 some adjuvant to or substitute for the use of the 
 knife, and until the last quarter of the century the 
 use of caustics in cancer therapy was regularly dis- 
 cussed in the standard surgical textbooks. There 
 are, however, few contributions to their technical 
 application and very little discussion of the kind 
 of cases to which they are applicable. Of all the 
 noted surgeons of his time Velpeau seems to have 
 made the most use of them, a paste designated as 
 "caustique noir," consisting of concentrated sul- 
 phuric acid made into a paste, being his favorite 
 formula. He says: *T have frequently employed 
 caustiQs in the treatment of cancer, and I have fre- 
 
 8 
 
quently thought, I must confess, that they have 
 more certainly prevented secondary cancerous af- 
 fections in the neighboring glands than the ex- 
 tirpation with the knife. I have twice seen volu- 
 minous and indurated glands in the axilla diminish 
 in a remarkable degree during the period I was de- 
 stroying a cancer of the breast by caustics, and I 
 have observed the same effect on the submaxillary 
 glands, while cancer ... of the lower lip was 
 treated in a similar manner." Maisoneuve also re- 
 fers repeatedly to the efficiency of caustics, espe- 
 cially of the chloride of zinc, in the removal of can- 
 cerous tumors, and of the long interval before they 
 recurred. Dupuytren, as a part of his armamenta- 
 rium, used a paste consisting of two parts of arse- 
 nic and 200 parts of calomel, which Parker refers 
 to as generally too feeble in its action. Manec, of 
 the Salpetriere Hospital, Paris, used a paste con- 
 sisting of one part arsenous acid, eight parts of 
 cinnibar, and four parts of burnt sponge, made into 
 a paste with a few drops of water. The results 
 from its use were favorably commented upon by 
 Lebert, who, Parker says, was not an ardent advo- 
 cate of caustics. All of these cases had been re- 
 ferred to Manec by other distinguished surgeons as 
 incurable. 
 
 Sir Astley Cooper is quoted by Parker as follows : 
 "It behooves medical men to direct their minds to 
 the trial of the numerous agents which chemistry 
 and botany have lately abundantly discovered and 
 simplified." Most of the pastes used during the 
 first third of the nineteenth century consisted either 
 of arsenic or the mineral acids, chiefly the former, 
 and numerous accidents resulted from their use. 
 Parker observed arsenic in the urine twelve hours 
 after the first application, which continued to be 
 
detected during a period of eight or ten days. Toxic 
 symptoms are recorded as occurring after the use of 
 such strong pastes as the very old one, known as 
 Frere Gome's, which is said to have cured Pope 
 Gregory X of a cancer of the face. Maisoneuve 
 mentions several cases in which its employment 
 produced vomiting, precordial anxiety and other 
 symptoms. 
 
 During the years 1834-1838 Ganquoin of Paris 
 reported the results which he had obtained from the 
 use of a paste, the essential ingredient of which was 
 chloride of zinc. He described four formulae, as 
 follows: (1) equal parts of zinc and flour; (2) zinc 
 one part, flour two parts; (3) zinc one part, flour 
 three parts ; (4) zinc one part, muriate of antimony 
 one part, flour 11/2 parts. Water from 20 to 30 
 drops for each formula. In 1838 a complete ac- 
 count of his results in 600 cases was published, in 
 which the recurrences were given as 12 per cent. 
 as compared with 75 per cent, after the use of the 
 knife. Regarding the details of its application he 
 says that formula (1) applied four lines in thick- 
 ness for 48 hours destroys the parts to a depth of 
 11/2 inches; that the same formula three lines in 
 thickness applied for the same length of time acts 
 only to about the depth of an inch. The depth to 
 which the paste acts can, he says, with a little prac- 
 tice be regulated to the utmost nicety, depending 
 upon its strength and the time it is applied. Plas- 
 ter of paris may be substituted for flour, thus ren- 
 dering it less delinquescent. The antimony was 
 added in formula (4) to give it the same consistence 
 as soft wax that it may be applied more uniformly 
 over an unequal surface, such as is presented by an 
 ulcerating growth. The advantage of the Ganquoin 
 paste over the arsenical preparations is attested by 
 
 10 
 
the fact that, with few exceptions, chloride of zinc 
 has been the effective ingredient of all pastes since 
 used by surgeons and quacks. Parker (1867) says: 
 "The chloride of zinc will effectually remove the 
 chief evil attendant on the application of caustic 
 remedies to the destruction of cancerous growths — 
 the amount of prolonged pain they occasion. It 
 may be applied with a degree of precision unob- 
 tainable by any other caustic ; it destroys the tissue 
 in direct relation with the thickness of the layer 
 applied; it never runs or fuses; it destroys only 
 those parts which it covers, and these it divides 
 from the surrounding structures as cleanly as 
 though they had been cut with a knife. The crust 
 or scab formed by this caustic is hard, dense, and 
 white; there is no sanguinous or other discharge 
 produced by it. The eschar separates at the end of 
 twelve or fourteen days, leaving a clean, healthy 
 granulating surface underneath." In 1855 there ap- 
 peared in the Dublin Quarterly Journal a method 
 introduced by Llandolfi, chief surgeon of the Sicil- 
 ian army and Clinical Professor of Cancerous Dis- 
 eases in the Trinity at Naples, in which he used 
 bromine, either alone or in combination with the 
 chlorides of zinc, antimony and gold. TTie introduc- 
 tion of this method was not enveloped in any mys- 
 tery, and Llandolfi's personality and method of 
 presentation produced such a favorable impression 
 in Paris, Germany and Vienna through which he 
 traveled that his paste was tried by many and 
 used with considerable success. 
 
 The efficiency of chloride of zinc is illustrated by 
 the story Parker relates of a Dr. Fell, an American, 
 who went to London and so successfully treated nu- 
 merous cases of cancer that a certain number of 
 patients at the Middlesex Hospital were placed at 
 
 11 
 
his disposal under the condition that he reveal and 
 publish the composition of his remedy. This was 
 ascertained to consist of equal parts of chloride of 
 zinc and a decoction of sanguinaria canadensis, with 
 enough flour to make a suitable paste. The hos- 
 pital staff were apparently favorably impressed with 
 the results. A little later, a Dr. Pattison, a London 
 homeopathic physician, in association with an 
 American from Louisiana, vaunted a remedy as a 
 sure cure for cancer without the use of the knife 
 or caustics, the results of which had evidently ob- 
 tained for the exploiters considerable fame and for- 
 tune. Their refusal to reveal the nature of their 
 remedy prevented its being tried at the Middlesex 
 Hospital, but it was subsequently found to be a 
 combination of chloride of zinc and hydrastis cana- 
 densis. Both Fell and Pattison administered the 
 "novelty" in their preparations also internally, the 
 latter in a dilution commensurate with his 
 homeopathic traditions. 
 
 It is clear that the staff of the Middlesex Hos- 
 pital, as well as surgeons of other hospitals, must 
 have had innumerable experiences of this kind, but 
 the results were evidently sufficient to make the use 
 of caustics — in the earlier years of arsenic, and 
 later, after the work of Canquoin, of the chloride 
 of zinc, an important adjuvant to the use of the 
 knife. Moore and De Morgan, of the Middlesex Hos- 
 pital, the former of whom is known especially for 
 his work in the development of the radical operation 
 with the knife, used weak solutions of chloride of 
 zinc — 20, 30, 40 grains to the ounce of water, after 
 their cutting operations in order to destroy cancer 
 cells that may have been disseminated through the 
 wound or the neighboring tissues. De Morgan 
 was so well satisfied with the improved results from 
 
 12 
 
this method that he expresses the hope that it will 
 be more extensively applied. They found that the 
 use of these solutions made no appreciable differ- 
 ence with the primary healing of their wounds. 
 
 A disadvantage in the use of the chloride of zinc 
 was its failure to satisfactorily remove the normal 
 skin over the tumor site, and for this reason in part 
 the alkaline caustics and mineral acids retained 
 their vogue. The well-kno'\;vTi Vienna paste consisted 
 of five parts of potassium hydrate and six of quick 
 lime. The "Filhos" caustic contained the same 
 ingredients in different proportions, and was fused 
 and run into leaden tubes like nitrate of silver or 
 potassa fusa. Of the mineral acids, nitric acid was 
 introduced by Rivallie (1850), in the form of mono- 
 hydrated nitric acid made into a paste with scraped 
 linen or charpie. For cancer of the servix uteri, 
 Routh (1866) advocated to the Obstetrical Society 
 of London the use of bromine — five grains to the 
 ounce of spirits of wine. Tilt indicates that in his 
 hands and others the application of the acid nitrate 
 of mercury to a cancer of the uterus produced satis- 
 factory results. 
 
 Reviewing the situation from the text-book litera- 
 ture of the sixth and seventh decades of the nine- 
 teenth century, we find Thomas (1869) expressing 
 the opinion that, if it should be impracticable to re- 
 move completely a cancer of the cervnx by amputa- 
 tion with the ecreseur, scissors, or the galvano- 
 cautery, it should be destroyed as completely as pos- 
 sible by the actual cautery, potassa cum calce, or one 
 of the mineral acids. Erichson says : ''The employ- 
 ment of caustics . . . requires neither knowl- 
 edge of anatomy nor of operative surgery, and so 
 they have always been popular with many who 
 would hesitate to use the knife. In this country, 
 
 13 
 
however, . . . they have not perhaps been 
 legitimately employed to the extent they deserve. 
 The chief argument in favor of caustics is that 
 when cancers are thus destroyed they are less liable 
 to relapse than when extirpated with the knife. 
 There is, however, no positive proof of this before 
 the profession; but it is not improbable that the 
 chemical action of the caustics may extend so widely 
 into neighboring structures as to destroy or render 
 unproductive the cancer cells by which they are in- 
 filtrated, and on the development of which the local 
 recurrence of the disease depends. Another advan- 
 tage urged in favor of caustics is that enlarged 
 glands are more likely to go down under their use 
 than when the primary cancer is extirpated by the 
 knife." In 1872 Bougard, a prominent Belgian 
 surgeon, wrote most enthusiastically of the advan- 
 tages in the use of caustics, stating that recurrences 
 were less frequent than after the use of the knife. 
 His formula, consisting largely of chloride of zinc 
 with a small amount of arsenic, was used by nu- 
 merous surgeons for several years. Willard Parker 
 (1873), in a paper on cancer of the female breast, 
 says: "In the superficial cancer of the breast it is 
 very well to use caustics. The same thing might be 
 said with regard to cancers upon the face. The 
 treatment with caustics in that region is good sur- 
 gery. When the tumor is situated to any extent 
 below the surface, the idea of caustics is bad sur- 
 gery." He referred to two cases of fatal poisoning 
 from their use. In the discussion of this paper 
 Fordyce Barker says : "Because of the general use of 
 caustics by charlatans a great majority of the surgi- 
 cal world have been satisfied with regard to their 
 uselessness. My own prejudices have always been 
 against this method of treatment." As a result of 
 
 14 
 
his observations in the St. Bartholomew's Clinic in 
 London, the whole process seemed so revolting that 
 he did not pursue his investigations further for 
 some time. In 1870, however, he became so pleased 
 with the work which he saw in the London Cancer 
 Institute by Marsden that he applied this method 
 of treatment successfully in two cases — one a can- 
 cer of the breast in which an operation with the 
 knife had been refused, the other a cancer of the 
 cervix uteri. He used the Marsden paste, which 
 consisted of equal parts of arsenious acid and 
 acacia. Sands, in his discussion of Parker's paper, 
 said that he had had no experience with the use 
 of caustics, but used the knife for the following 
 reasons: (1) Nature of the tumor can not be de- 
 termined prior to its removal; (2) now and then 
 undoubtedly a malignant tumor is cured by opera- 
 tion; (3) expediency. J. Collins Warren says: "I 
 have had little experience with the use of caustics. 
 I find little difficulty in persuading patients to re- 
 sort to more radical measures." About the face, 
 to rodent ulcer, he preferred the use of the cautery, 
 especially near the angle of the eye, because there 
 resulted less of a scar, it being more difficult, he 
 thought, to be economical of tissues with the knife, 
 and more deformity resulted than when nature is 
 allowed to borrow skin from all directions. 
 
 Stephen Smith (1880) describes his use of the 
 anhydrous sulphate of zinc in the form of a powder, 
 using a strong sulphuric acid paste for the removal 
 of the skin. He says : 'This remedy, though all but 
 discarded by surgeons in the treatment of cancer, 
 has a place in the therapeutics of cancer not yet ac- 
 curately defined. It is one of the destructive meas- 
 ures which we may resort to, having capacities 
 limited only by the possibilities of its application. 
 
 15 
 
As ordinarily employed, its real virtues are not 
 fairly^nor adequately defined. We are advised, or 
 rather permitted by authorities to apply caustics to 
 ulcerated cancerous surfaces, the growth no longer 
 being amenable to the knife. That is, caustics are 
 recommended as a last resort, when the disease has 
 taken such deep root that it is certain to prove 
 fatal. If useful under such circumstances, may they 
 not be far more serviceable at an earlier period? 
 In my experience caustics judiciously selected and 
 thoroughly and persistently applied give the best 
 results of any method of treatment yet adopted." 
 Dabney (1882) also reports favorable results from 
 the use of this powder. Billroth (1889) expressed 
 his preference for the use of the knife, but in very 
 old, anaemic, or timid patients, thought caustics 
 may be employed, and, if the treatment be continued 
 until all the diseased portion is destroyed, the result 
 will be favorable. "Physiologically," he says, "caus- 
 tics would have some advantages; for it is sup- 
 posable that the cauterizing fluid may enter the 
 finest lymphatic vessels, and thus more certainly 
 destroy the local disease. But this does not occur 
 readily, because the tissue with which the caustic 
 comes in contact instantly combines with it, and its 
 further flow is thus prevented." For a caustic Bill- 
 roth preferred chloride of zinc. Robinson (1892), in 
 discussing the treatment of cutaneous epitheliomas, 
 says that caustics with less scar remove more tissue 
 than the knife. He used caustic potash and the 
 formula of Bougard. Lewis (18931) used the Mars- 
 den paste for a number of years in the treatment 
 of superficial cancer of the skin. Snow (1893) 
 writes of the advantages obtained in the use of caus- 
 tics on small superficial lesions, and in chronic 
 epitheliomas, or rodent ulcers. He considered 
 
 16 
 
potassa fusa to be the most thorough and rapid, its 
 action being instantaneously checked by the use of 
 water, and causing no subsequent pain or shock. 
 Parmenter (1894) says that it has not been proved 
 whether caustics are better or worse than the knife, 
 but he believes that the intelligent application of a 
 proper caustic to easily accessible and definitely 
 localized tumors, such as those of the skin, lip and 
 external ear, has many advantages. Bulkley (1894) 
 has found use for Marsden's paste, the potassa fusa, 
 and Bougard's formula in early superficial malig- 
 nant growths. Allen (1904) takes exception to 
 White's statement that "the caustic treatment in 
 the form of injections, pastes, and all other kinds 
 of mixtures, rarely prove of any service, and usually 
 only deceive and render more uncomfortable the ex- 
 istence of a patient. They have been discarded by 
 almost all except charlatans." Impressive evidence 
 of the value which the proper application of caustics 
 may still possess in cancer therapy is furnished by 
 the following words of Halsted (1907), in a paper 
 on Carcinoma of the Breast: "I am indubitably 
 convinced that the local and regionary recurrences 
 after incomplete operations, which come with amaz- 
 ing rapidity when the knife has been used, are, to 
 say the least, relatively late in making their appear- 
 ance when chemical or actual cauterization has been 
 employed. I have several times had to operate upon 
 cancers which had been vigorously and repeatedly 
 treated with caustics, and to note the comparatively 
 admirable condition, the freedom from cancer 
 premeation of the surrounding tissues and of the 
 axillary nodes ; whereas, after incomplete operations 
 with the knife the local manifestations of recur- 
 rence were almost invariably deplorable and the 
 prognosis, of course, invariably hopeless." He also 
 
 17 
 
says, "I doubt if any melanotic tumor of the skin 
 should be removed with the knife." 
 
 From this review we learn that since the begin- 
 ning of the nineteenth century chemical caustics 
 were an increasingly valuable resource of all the 
 noted surgeons in cancer therapy until Langston 
 Parker (1867) in the Annual Address in Surgery, 
 before the British Medical Association, showed that 
 they had become a fair rival of the knife. In spite, 
 however, of the undoubted success which attended 
 their use during this period, we find that they were 
 being applied less frequently by the skillful surgeons 
 during the last quarter of the century. During the 
 early years of the tv/entieth century their position 
 in cancer therapy is not unlike that described by 
 Young over one hundred years ago. "Caustic appli- 
 cations," he says, "were ushered in under the 
 equivocal sanction of a nostrum, they were pursued 
 as a nostrum, and then they were turned out as a 
 nostrum. All regular inquiry has been withheld 
 from the merits of the practice, and because it did 
 not succeed in all things its efficacy was not allowed 
 to any. Thus transferred from the irregulars to 
 the regulars it was turned back to its original 
 holders." 
 
 In the light of this history it may not be un- 
 profitable to ask if they have a field for use at the 
 present time? 
 
 Regarding the continuation of their use by the 
 "original holders," we may hope that our educa- 
 tional propaganda and a more intelligent legislative 
 restraint will ultimately solve that part of the prob- 
 lem. The question of renewal at the present time 
 of the consideration of their efficacy by the educated 
 surgeon naturally reverts to an estimate of their 
 value when previously used and to the reason for 
 their abandonment. 
 
 18 
 
Their value as compared with the operation by 
 the knife was apparently not satisfactorily defined 
 at the time they were given up. No statistical data 
 were available. We know that operations with the 
 knife during a greater part of the nineteenth cen- 
 tury were almost invariably incomplete and that the 
 cures were few. Sands says, "Now and then a cure 
 was accomplished." After the use of the chemical 
 caustics, however, we have the evidence of numer- 
 ous com-petent observers that the interval before re- 
 currences appeared w^as often long, and there is 
 much reason to believe that cures were more fre- 
 quent than after operations with the knife. The 
 danger from poisoning was made a negligible factor 
 by the very general substitution of zinc chloride for 
 arsenic. 
 
 We do not find therefore that their value in the 
 hands of competent surgeons was discredited, but 
 the reason for their abandonment appeared to be 
 in the new conception of the possibilities which 
 scientific medicine furnished to the practical sur- 
 geon during the closing years of the century. Patho- 
 logical anatomy was making an early and exact diag- 
 nosis more available, the results of bacteriological 
 research promised to make primary mortality a 
 negligible factor and primary healing of the wound 
 a definite certainty, thus encouraging the surgeon 
 to believe that ultimately the development of his 
 technique would preclude the necessity of using 
 chemical methods which were less attractive and ex- 
 tremely difficult to apply. Frequent and early recur- 
 rences could not obliterate the attractiveness of the 
 primary result, and, until the past decade, sufficient 
 solace could always be obtained in the idea that con- 
 stitutional taint or heredity were compelling factors 
 in the unfavorable progress of the disease. 
 
 19 
 
The result is that the "salvage," as expressed by 
 Clark in regard to uterine cancer is greater, but, 
 owing to our failure to increase appreciably the 
 number of patients applying for treatment in the 
 earliest stages of the disease, the primary mortality 
 has markedly increased, operative sequellse are fre- 
 quent, and recurrences are still discouragingly large. 
 The words of Peterson (1912) are important, who, 
 after expressing his strong belief in the radical 
 operation for carcinoma of the uterus, says, "My 
 added experience has not made me any more confi- 
 dent that the next patient I operate upon will either 
 survive the primary operation or will ultimately be 
 cured." Finally, there is the important fact that 
 the availability of surgical skill sufficient to effect 
 a respectable salvage is extremely limited — as much 
 so as is that of radium. 
 
 We believe, therefore, that the evidence of the 
 value of chemical caustics is sufficiently strong to 
 justify a new study of their technical application 
 and a discussion of the kind of cases in which they 
 may be most efficiently applied. In so doing they 
 may afford a valuable adjuvant to the use of the 
 knife and become applicable to a number of well 
 developed growths, the extirpation of which at the 
 present time results in a high primary mortality 
 and a high percentage of recurrences. 
 
 Regarding the educational propaganda of cancer, 
 it seems to the writer that the study and applica- 
 tion of all reasonable methods of treating cancer 
 will be of aid in encouraging the public to seek early 
 relief from competent hands. While anaesthesia 
 and skill have diminished the dread of the knife, the 
 fear of an operation still remains an important rea- 
 son for the frequent delays in asking for advice. 
 
 20 
 
BIBLIOGRAPHY. 
 
 Allen: The Treatment of Cancer by Caustic Pastes. 
 Medical Record, 1904, 64, 935. 
 
 Arndt: Historisch-kritische Uebersicht ueber die zu 
 den Verschiedenen Zeiten in der Krebshandlung erziel- 
 ten Erfolge. Inaug. Dissert. Berlin, 1884. (Contains 
 literature.) 
 
 Barker, Fordyce: Discussion of Willard Parker's 
 paper. 
 
 Billroth: Surgical Pathology, Hackley, 1899. 
 
 Bougard: Sur la guerison du Cancer, Bruxelles, 
 1872. 
 
 Bulkley: On the Use of Caustics in Malignant Dis- 
 ease. Journal Am. Med. Assn., 1894, 22, 982. 
 
 Canquoin : Memoire sur un nouveau Mode de Traite- 
 ment des Affections Cancereuses. Paris, 1835. 
 
 Canquoin: Traitement du Cancer. 
 
 Chauliac, Guy de: Arndt and Wolfe. 
 
 Clark, J. C: The Radical Operation for Cancer of 
 the Uterus. Trans. Amer. Gyn. Soc, 1912, 37, 269. 
 
 Clowes : Wolfe. 
 
 Come: Langston Parker. 
 
 Cooper, Sir Astley: Lectures on Surgery, 1802. 
 
 Dabney: The Use of Anhydrous Sulphate of Zinc as 
 Caustic in Cancerous Ulcers. Med. News, 1882, 40, 401. 
 
 Dupuytren: Cited by Langston Parker. 
 
 de Mondeville, Henri: Arndt and Wolfe. 
 
 De Morgan : BHt. and Foreign Medico-Chir. Review, 
 Jan., 1866, 201. 
 
 Erichsen : The Science and Art of Surgery, 1860. 
 
 Fell: Cited by Langston Parker. 
 
 Filhos : De la Cauterisation du Col de I'Uterus avec le 
 Caustique Solidifie de Potasse et de Chaux, Paris, 1847. 
 
 Halsted: The Results of Radical Operations for the 
 Cure of Carcinoma of the Breast. Annals of Surgery, 
 1907, 46, 1. ^ 
 
 Hunter, John: Wolfe. 
 
 Hildanus, Fabricius: Wolfe. 
 
 Llandolfi: Dublin Quarterly Jour., Nov., 1855. Trans- 
 lation of Lasegue's Review of Llandolfi's Treatment of 
 Cancer. 
 
 Lewis: The Use and Place of Caustics in the Treat- 
 ment of Cancer. Annals of Surgery, 1893, 17, 392. 
 
 Maisoneuve : Lecons Cliniques sur les Affections Can- 
 cereuses, Paris, 1852-4. 
 
 21 
 
Manec : Cited by Langston Parker. 
 
 Marsden : Cited by Langston Parker. 
 
 Moore: Jour. Brit. Assoc, April 21, 1866, 406. 
 
 Pare, Ambroise: Arndt and Wolfe. 
 
 Parker, Langston: The Modern Treatment of Can- 
 cerous Diseases by Caustics or Enucleation. London, 
 1867. Annual Address in Surgery Before the Brit. Med. 
 Assoc. (Contains literature.) 
 
 Parker, Willard: Cancer of the Female Breast. Its 
 Character, Diagnosis, Prognosis, and Treatment. Med- 
 ical Record, 1873, 8, 431. 
 
 Parmenter: On the Use of Caustics in Malignant 
 Disease. Journal Am. Med. Assn., 1894, 22, 982. 
 
 Pattison: Cancer: Its Nature and Successful and 
 Comparatively Painless Treatment, 1866. 
 
 Peterson: Primary and End Results of 51 Radical 
 Abdominal Operations for Cancer of the Uterus. Trans. 
 Amer. Gyn. Soc, 1912, 37, 295. 
 
 Peyrilhe: Cited by Wolfe. 
 
 Recamier: Recherches sur le Traitement du Cancer 
 par les Compression, etc. Paris, 1829. 
 
 Rivallie: Traitement du Cancer par TAcide Nitrique 
 Solidifie. Paris, 1850. 
 
 Robinson: Some Considerations on the Treatment of 
 Cutaneous Malignant Epitheliomata. International 
 Jour. Surgery, 1892, 5, 179. 
 
 Routh: A New Mode of Treating Cancer of the 
 Cervix Uteri. Obstet. Soc. of London, Oct. 3, 1866. 
 
 Sands: Discussion of Willard Parker's Paper. 
 
 Smith, Stephen : The Treatment of Cancerous Ulcers 
 and Growths Not Removable by the Knife. Medical 
 Record, 1880, 17, 165. 
 
 Snow: The Path of Improvement in Cancer Treat- 
 ment. Med. Press and Circular, 1893, 1, 659. 
 
 Storck : Cited by Arndt. 
 
 Thomas, T. G.: Diseases of Women, 1869. 
 
 Tilt: The Change of Life in Health and Disease. 
 
 Velpeau: Traitement des Maladies du Sein, et de la 
 Region Mammaire, etc., 1854, 63, 676. 
 
 Warren, J. Collins: Personal Experience in the 
 Treatment of Cancer. Boston Med. and Surgical Jour., 
 1887, 116, 154. 
 
 Wolff: Die Lehre von der Krebskrankheit, 1907. 
 (Contains the older literature and a historical review 
 of the use of caustics among the ancients and during 
 the middle ages.) 
 
 22 
 
Woelfler: Zur Geschichte und Operativen Behand- 
 lung des Zungenkrebses. Archiv. f. kl. Chir,, 26, 314. 
 (Contains literature.) 
 
 Young: An Inquiry into the Nature and Action of 
 Cancer. London, 1805. 
 
 23 
 
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