Personal Experience 
IN THE 
Treatment of Cancer. 
J. COLLINS WARREN, M.D., 
Associate-Professor of Surgery, Harvard University; Surgeon to th 
Massachusetts General Hospital. 
Reprinted from the Boston Medical and Surgical Journal 
of February lyth, 1887, 
BOSTON : 
CUPPLES AND HURD, Publishers, 
No, 94 I|oylston Street, 
■ rBBT, Compliments of 
J. C. WARREN, M.D. PERSONAL EXPERIENCE IN THE TREATMENT 
OF CANCER.1 
Associate-Professor of Surgery, Harvard University; Surgeon to the 
Massachusetts General Hospital. 
J. COLLINS WAEKEN, M.D., 
I have chosen this title for my paper this evening, 
not with the intention of bringing before the Society 
any new or original mode of dealing with this 
disease, nor of presenting any carefully-tabulated series 
of cases, but simply for the purpose of recording a few 
of the conclusions which I have arrived at, in the hope 
that they may not be without interest to others. 
I regret to say that I have no data which throw any 
light on the etiology of this disease. It may not be 
out of place, however, to notice a few facts bearing 
upon this point which the literature of this subject 
affords. The influence of locality seems to be not 
without its effects upon individuals. A notable exam- 
ple of this has been observed in the cobalt mines of 
Schneeberg, where all the men, who work a certain 
number of years in the mines, die of lympho-sarcoma 
of the lungs, but none of the persons employed in the 
neighborhood are affected with this disease. 
It has been said that in tropical climates cancer is 
much less frequent than in the temperate zone, but I 
have not had an opportunity of studying any statistics 
bearing upon this point. It is stated that Dr. Haviland 
has found from statistics that, while high and dry 
lands are free from cancer, the sources of large rivers 
subject to seasonal overflow are hot-beds of cancer, 
the inference being drawn that the organisms of cancer 
1 Read before the Boston Society for Medical Improvement, January 
24,1887. 2 
thrive only or chiefly in moist districts, or in the 
tissues of those who reside in moist river districts.2 
So far as I am aware, no such geographical distribu- 
tion of cancer has been observed in New England. 
It would exceed the scope of this paper to endeavor 
to accumulate evidence upon the origin of cancer from 
injury or inflammation. Examples of cancer follow- 
ing a continual irritation are sufficiently numerous as 
in the lip, to justify the assumption that there may be 
some relation between the local irritation and the new 
growth. One of the most malignant forms of cancer 
of the breast that 1 have seen, dated its development 
from a blow. The patient was a healthy and finely- 
developed Irish servant-girl, under thirty years of age. 
She received a severe blow from a base-ball, and the in- 
flammation thus produced left a hardness, which did 
not disappear. So rapid was the growth, that an ex- 
ploratory incision was needed to confirm the diagnosis 
of cancer. 
A chronic balanitis, with thickening of the prepuce, 
due to an attempt on the part of a patient to cure a 
phymosis with a razor, was followed by an epithelial 
ulcer in the sulcus below the corona. Excision of 
the ulcer in this case had not been followed by a re- 
turn of the disease when the patient was seen a year 
or two later. 
On the other hand, there may be a chronic inflam- 
mation of an organ, frequently attacked by cancer, 
which may continue for a long time without the devel- 
opment of any malignant growth. More than one 
case of chronic mastitis, with inversion of the nipple 
and a gland in the axilla, have been sent to me for a 
diagnosis, which have terminated either in resolution 
or suppuration. In two cases at present under obser- 
vation, the inflammation appears to have been caused 
2H. T. Butlin. International Encyclopedia of Surgery, Yol. IV. 3 
by the malformation of the nipple which had always 
existed. 
We hear less of the influence of heredity in cancer 
to-day than did the students of twenty years ago ; an 
example given by Sir James Paget is, however, suffi- 
ciently striking to quote : A lady died with cancer of 
the stomach; one of her daughters died with cancer of 
the stomach, another with cancer of the breast; of 
her grandchildren, two died of cancer of the breast, 
two of cancer of the uterus, one of cancer of the axil- 
lary glands, and one of cancer of the rectum. An 
almost equally marked example is furnished in the 
case of Miss 8., reported below. T have, however, 
little faith in hereditary tendency, at least, so far as 
cancer is concerned. 
CANCEH OF THE FACE. 
It has been the fashion, particularly in England, to 
divide cancer of this region into two varieties, namely, 
cancer of the lip and rodent ulcer. 
The great variety of growths placed in the latter 
category present essential differences, both in develop- 
ment and outward appearance. In many, the ulcerat- 
ing type is absent. They all present a mild type of 
malignancy, although there may be great variations in 
this respect within certain limits. 
It has been stated that these growths occupy the 
region of the face situated above the line of the mouth, 
and this is undoubtedly the case, as a rule. I have, 
however, at present under treatment a case of epithe- 
lioma of the rodent type upon the chin, and have ob- 
served them even upon the neck, behind the ear. 
That variety which is usually developed from the 
epithelial layers of the skin, and frequently accompa- 
nied by that condition of the skin of the face and 
hands known as keratosis senilis, is apt to be multiple, 4 
and some of these growths may become quite volumi- 
nous. Both this variety and that which springs from 
the sebaceous glands may, at times, assume the ulcer 
type, though this form does not seem to belong essen- 
tially to either. 
I am inclined to agree with Mr. Hutchinson’s view, 
that locality has a strong influence upon type. The 
ulcerating form is most frequently seen near the nose 
and eyelids ; the papillary or tuberous form more fre- 
quently on the cheeks and temples. The crateriform 
ulcer recently described by this author is an example 
of an active-cell growth, with consequent central de- 
generation. It is one of the most exuberant and 
active types of the so-called rodent ulcer family. A 
very perfect example of this disease I had the oppor- 
tunity of watching from its early stages recently. At 
first a nodular mass was seen on the right temple, 
about the size of a small nipple. The centre was 
slightly umbilicated. A sudden increase in the rapidity 
of growth, with corresponding increase in the size of 
the central depression, developed its crater-like ap- 
pearance, and necessitated active surgical interference. 
Examples of the multiple growths are not uncom- 
mon. Mr. J. B. M., a gentleman sixty odd years of 
age, has been under ray observation for ten years, 
during which time a very large number of epithelial 
growths have been removed from the face and hands, 
some of considerable size. During this period he has 
also been under Dr. White’s care for a very striking 
form of keratosis. One of those curious freaks of 
which many diseases are capable has occurred within 
the past year. Last summer he had a small growth 
removed from the eyebrow. A larger growth of epi- 
thelium was beginning to form on one ear, and a fresh 
outbreak of the disease appeared imminent. A sudden 
and marked improvement began about three months 5 
ago, and his face and hands appear to be entirely free 
from keratosis. He attributes this change to the per- 
sistent use of vaseline at night. 
I have had but little experience with the use of 
caustics, as I find little difficulty in persuading patients 
to resort to more radical measures. Very small 
growths may be destroyed by an application of nitric 
acid, or boring with a pencil of nitrate of silver. 
When not of minute size the question of deformity 
becomes the most important one in determining be- 
tween excision or the curette and cautery. Small 
epithelial growths or ulcers may be neatly removed 
by excision. A linear wound, held together by two 
or three stitches, needs no dressing and unites by first 
intention. If the sutures are removed early the scar 
will soon be difficult to find. The cautery will be 
much more likely to leave a visible scar in the shape 
of a smooth and white and slightly depressed cicatrix. 
If, however, the disease is situated in some sharp 
angle of the face, as in the neighborhood of the nose, 
it is difficult to be as economical of tissues with the 
knife as with the cautery, and the use of sutures is 
liable to bring the edges of the wound together in a 
way which will produce more deformity than when 
nature herself is allowed to borrow skin from all direc- 
tions. A prominent ridge near the nose or eye may 
be avoided by allowing the wound to heal by granu- 
lation. 
When larger wounds are necessary, an attempt at 
healing by first intention will cause some constitutional 
disturbance which may not be desirable in old and 
feeble individuals. The cautery leaves an open 
wound protected by an eschar, and subsequent pain 
and fever are rarely observed. Ordinarily these 
wounds need no dressing for the first few days, and 
when of considerable size may heal by scabbing. Oc- 6 
casionally there may be a secondary haemorrhage, 
which is usually a slight affair and easily checked, but 
it is likely to alarm the patient and necessitate an un- 
comfortable bandage. In extensive disease or irreg- 
ular-shaped growth of the face, however, it causes far 
less deformit}' than the knife. The curette should 
always be used with the cautery, as the soft superficial 
masses of epithelium are readily removed in this way ; 
the finger-like projection of epithelium into the subja- 
cent fibrous stroma can be readily attacked by the hot 
platinum. The curette should never be used alone 
even in the smallest growths, for there is almost in 
every case a projecting off-shoot of the disease pene- 
trating the denser tissues which will escape the instru- 
ment. The stick of nitrate of silver may be substi- 
tuted for the cautery in such cases. 
A striking instance of the advantages of the cautery 
(Paquelin) has recently occurred to me. The disease 
had involved the integuments of one side of the nose 
and an adjacent portion of the cheek, and had begun 
to invade the opposite side. One ala was entirely 
destrojmd, and the part above the inner canthus of the 
eye, a dangerous locality from a prognostic point of 
view, was on the point of being invaded. A, thorough 
use of Paquelin’s cautery, under ether, completely 
removed the growths at one operation and the nose is 
now covered with a clean and smooth cicatrix. No 
pain or constitutional disturbance was experienced at 
any time by the patient, who was seventy-five years of 
age. For several days the eschar served as an excel- 
lent dressing, and no other was used until later. 
Since the introduction of cocaine, I have used it in 
several cases with satisfactory results. An ulcer on 
the chin, about the size of a half-dollar, was cauterized 
without pain, althoiigh the epithelial masses penetrated 
quite deeply. No other assistance was given than 7 
that of the patient himself, who worked the bulb vigor- 
ously while the cautery was applied. It was necessary 
to use the subcutaneous injection of a few drops of 
a twenty per cent, solution at several points in the 
periphery of the ulcer. Alarming symptoms have 
been reported as following the use of three drops 
of a solution of this strength under the mucous 
membrane of the mouth. I have noticed on two oc- 
casions in this patient, symptoms of faintness and dis- 
tress apparently due solely to the cocaine, but these 
have followed also the injection of a ten per cent, 
solution in the same individual. The anaesthesia has 
not been complete in this case, except after the use of 
the twenty per cent, solution. Where there is an 
ulcerated surface it can be painted over with one of 
the weaker solutions with good effect. It promises to 
replace ether in a certain number of cases. 
The care of the skin is an important feature of these 
cases. The epidermis must be kept in a soft and 
pliable condition, and not allowed to accumulate. 
Various substances, as salicylic acid or zinc in vaseline 
as a vehicle, may be applied after washing with appro- 
priate soap. The liability to recurrence varies, of 
course, with the progress the disease has made, but 
some cases recur with obstinacy even when removed 
at an early stage. An example of this characteristic 
is shown in the case of Mrs. P., aged about sixty, 
from whom I removed a nodule on the bridge of 
the nose, in 1872. A suspicious scab was removed 
shortly after, but the microscope failed to detect any 
cancerous cells in it. The disease returned in about 
eighteen months, and before she could make up her 
mind to another operation, had involved the integu- 
ments of the whole bridge of the nose. It was thor- 
oughly cauterized under ether, but in a year or two it 
broke out again; treatment was continued until 1883, 8 
but as I was unable to promise a. radical cure the pa- 
tient finally abandoned treatment. She is, I think, 
still living with a well-developed rodent ulcer on this 
region. 
As a contrast to this case, that of Mr. S., eighty- 
two years of age, may be mentioned. He was operated 
upon in May, 1882, for an extensive ulcer at the outer 
canthus of the right eye, involving the conjunctiva and 
some of the tissues of the orbit. Although the sight 
of the eye has been destroyed, there has been no re- 
turn of the disease. He has consulted me since for 
several small nodules near the lid of the left eye. 
The favorable results which have attended a more 
radical operative treatment of this affection have given 
encouragement to surgeons to hope for cure in many 
cases which formerly were thought suitable only for 
palliative measures. 
The rule has been laid down by some authors that 
in all cases there should be a thorough dissection of 
the axilla, whether glands are felt there or not; and 
some, notably Dr. S. W. Gross, of Philadelphia, re- 
commend a more extensive removal of the tissues of 
the breast, leaving often a wound which can only be 
healed by grafting. 
The anticipation of glandular disease of the axilla, 
seems to me a very important step forward in the 
surgery of the breast. The lymphatic vessels and 
glands, which are the routes through which the disease 
travels, are destroyed, and isolation of the disease is 
more effectively produced in this way than in any 
other. Small glands may, moreover, already exist, 
which can be detected by the touch of the finger 
through the integument. It has been my experience 
to dissect out the pyramidal mass of fat which fills this 
CANCER OF THE BREAST. 9 
region, and to find one or two nodules enclosed in its 
centre, which could not be felt before the operation. 
The ordinary duration of this disease, if left un- 
treated, is said to vary from six months to three years, 
taking the average of cases. With this period as a 
standard, it will be seen that life is not prolonged in 
many cases by the operation; but a careful inquiry 
into the future history of hospital patients would, I 
think, bring out replies which would prove encouraging. 
The following cases are selected as fair samples of 
what may be accomplished by the present more radi- 
cal operation : 
Eighteen months' immunity. Mrs. 8., Amesbury, 
Mass., about sixty years of age. Disease had existed 
two months. A hard and voluminous cancer of the 
breast, with large glands in the axilla, extending as 
high as the clavicle. The breast was amputated and 
the axilla carefully dissected out, all glands having 
apparently been removed. The case was not promis- 
ing, and one which, in former times, I should have de- 
clined to operate upon. The operation was performed 
July 9, 1885, and Dr. H. G. Leslie writes me at pres- 
ent date that there is no evidence of a return of the 
disease. 
Nearly two years' immunity. J. D., about forty-five 
years of age. was operated upon at the hospital, 
March 29, 1884. She had had a tumor nine months ; 
at the time of the operation it was the size of an 
orange. The records state that no axillary glands 
were removed, although the cicatrix was seen to ex- 
tend two or three inches beyond the edge of the pec- 
toral is major when she was examined on her return to 
the hospital last week, for the removal of a small 
nodule in the cicatrix, at the axillary end, about the 
size of a coat-button. No glands are felt in the axilla. 
The microscopic examination by Dr. Whitney showed 
the original tumor to be a medullary cancer. 10 
Two years’ immunity. Miss 8., about forty years 
of age, was operated upon in December, 1884. Had 
first noticed a tumor in breast the previous winter, but 
had noticed an eczema of the nipple in 1883. A care- 
ful dissection of the axilla was made in this case, al- 
though no glands were felt. On opening the mass of 
fat removed, one small cancerous nodule was found in 
its centre. Inquiry of her physician, Dr. C. P. Put- 
nam, last December, elicited the fact that no return of 
the disease had been reported at that date. 
An interesting feature of her history was the preva- 
lence of the disease in her family. Her maternal 
grandmother died of cancer of both breasts, at the age 
of thirty. A maternal aunt died of cancer of the 
breast. A cousin on mother’s side died of cancer of 
the rectum. Aunt on father’s side was operated upon 
at the hospital in 1883, for a cancer of the breast. 
Two-and-a-half years' immunity. Miss J., Haver- 
hill, Mass., was operated upon in June, 1884. The 
breast was very voluminous, and the cancerous nodule 
was small, and situated near the sternal boundary. 
Nevertheless, the incision was carried into the axilla, 
and a portion of the axillary fat removed. I have 
seen the patient quite recently ; her health is excellent, 
and she is able to attend to all her duties, which are 
quite onerous. 
Three years' immunity. Grace M., forty-five years 
old, was operated upon at the hospital in July, 1883, 
for a scirrhus of three years’ standing, which had not 
involved the axilla. The tumor had slowly increased 
in size during this time, and the nipple was extracted. 
She was seen last spring and carefully examined, the 
parts being found in a perfectly healthy condition. 
Her health is good, and she has been in active service 
since the operation. 11 
Two other localities which are occasionally the seat 
of cancer may be briefly mentioned in this paper. 
CANCER OF THE RECTUM 
would not appear to me to be of so frequent occur- 
rence in this country as in England or the continent 
of Europe, comparing own experience with the 
statistics of foreign writers. The worst form of this 
disease which I have met with has been in the case of 
two young women. 
The first case was a woman, twenty-three years of 
age. The symptoms were of one year’s standing, 
when she entered the hospital. The patient suffered 
great pain in defecation, but the anus was not in- 
volved, the disease being wholly within the rectum, 
which it nearly filled with a very dense mass of tissue. 
An incision through the disease and sphincter was per- 
formed, with but temporary relief, and a few weeks 
later lumbar colotomy was performed, which gave con- 
siderable relief, which continued until her death, about 
nine months later. 
The second case was a lady about thirty-five years 
■old, with a voluminous growth springing from the an- 
terior wall of the rectum, and filling out the perineum. 
The pain in this case seemed to be due largely to the 
growth of the mass, and was principally in the hip. 
There was also tenesmus and frequent desire to defe- 
cate although no obstruction. An active application 
of the actual cautery was made, as it was feared that 
colotomy would not relieve the symptoms in this case. 
The operation freed her from pain, but she sank and 
died apparently from no special inflammatory process, 
about three weeks later. 
Attempts at extirpation have been quite unsatisfac- 
tory, and I am inclined to advise as little interference 
with the disease locally as possible, unless it be seen 12 
at a very early stage. But such a case has never pre- 
sented itself to me. Indeed, I have never seen one 
where it seemed mechanically possible to remove the 
whole growth. 
Colotomy is a palliative operation in certain cases, 
but not by any means in all; for those near the anus 
it may relieve the acute local pain ; for those higher 
up it is only indicated in case of marked obstruction,, 
which, however, does not always occur. 
CANCER OF THE (ESOPHAGUS. 
My experience with dilatation of the stricture pro- 
duced by the disease in this locality has not been en- 
couraging, The painful nature of the treatment and 
the rapidity with which obstruction occurs on its dis- 
continuance, make this a method unsatisfactory to both 
sui’geon and patient. On one occasion, an attempt to 
pass the ivory probang in a very old lady with can- 
cerous stricture, although made with great care and 
gentleness, was followed by death of the patient three 
days later. In another case, the persistent and most 
careful use of the bougie, although it kept the strict- 
ure from closing entirely, did not prevent great irrita- 
tion of the oesophagus from obstruction. Considera- 
ble inflammation occurred around the locality of the 
disease, tracheotomy was performed, and at the au- 
topsy, some weeks later, perforation of the oesophagus 
was found, with the production of which, of course, I 
had the privilege of being accredited. In a case 
which has been under treatment during my present 
service at the hospital, I have accordingly tried the 
operation of gastrostomy. Until the termination of 
the case it will not be possible to express an opinion 
on its merits and disadvantages. The management of 
the fistula requires an amount of intelligence which 
the average hospital patient cannot always be depend- 
ed upon to, possess. 13 
The use of a flexible tube permanently retained in 
the oesophagus offers certain advantages over either of 
the other methods, which would incline me to give it 
a trial. 
In regard to the efficacy of drugs in the treatment 
of cancer, I have had no positive results. 
Arsenic has been tried repeatedly in cases of 
lympho-sarcoma, without the slightest success. In a 
recent case of this disease an exploratory incision was 
made, and since the wound thus made has healed, the 
tumor has slightly decreased in size. This result may 
have been due to severing some of the vascular con- 
nections of the tumor. 1 have used chian turpentine 
also in several cases, without any effect, in cancer of 
the breast, of the oesophagus and rectum. 
The recent publication by Mr. Clay, of cases of suc- 
cessful treatment of cancer of the lip, tongue and 
uterus, has again called attention to this drug, and the 
mode of administering it is accordingly given here. 
Mr. Clay maintains that physicians are too easily dis- 
couraged, and that its administration should be contin- 
ued through the period of at least three months, in 
order to obtain favorable results. 
The mixture which Mr. Clay recently recommended 
was the following: 
Chian Turpentine .... 3 iss. 
Flor. Sulpli 3 i. 
Divide into thirty pills. 
Magnesia should not be used as an excipient, and 
they should not be coated. 
Two pills should be taken three times a day for 
three weeks; then three pills three times a day, or 
twenty-seven grains of chian turpentine daily. They 
should be taken about one-half hour after eating ; after 
being taken for three months, they should be discon- 
tinued for three days in every fortnight. Messrs. 14 
Metcalf & Co., write me: “The mixture he has made 
contained five grains of the chian turpentine and two 
grains of sulphur to the teaspoonful, made up with 
mucilage of tragacanth. The pills have been much 
used, but the mixture being rather unsightly and not 
agreeable to the palate, has fallen out of use.” The 
“ Southall ” mixture, which he has recently advised, 
contains resorcine instead of sulphur, but its composi- 
tion I have not been able to ascertain. I have myself 
used the following combination : 
ii Chian Turpentine. 
liesorcine . . . . 3aa ii. 
Mucilag. Gum Aoac. . . 3 ii. 
Aq. Oinnam. . . . 3i- 
Sig. Teaspoonful three times a day. 
If carefully prepared it is not a disagreeable mix- 
ture, but most patients prefer the pills. 
I am one of those who are hopeful that a bacterial 
study of this affection may further our knowledge of 
its etiology, and pave the way to a more intelligent 
treatment. It may be that, like the treatment of 
traumatic infective diseases, this may be prophylactic 
rather than curative. But it hardly seems possible 
that with so rapid advances in surgical knowledge in 
other directions, we should still continue to remain 
nearly helpless to aid humanity affected with so terri- 
ble a disease. THE BOSTON 
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