Extracted from 
The American Journal of the Medical Sciences for October, 1892. 
MULTIPLE SARCOMATA. HISTORY OF A CASE SHOWING 
MODIFICATION AND AMELIORATION OF SYMPTOMS 
UNDER LARGE DOSES OF ARSENIC. 
By Samuel Sherwell, M.D., 
CLINICAL PROFESSOR OF DERMATOLOGY, LONG ISLAND COLLEGE HOSPITAL; ATTENDING PHYSICIAN, 
BROOKLYN HOSPITAL J SURGEON TO SKIN AND THROAT DEPARTMENT, BROOKLYN 
EYE AND EAR HOSPITAL. 
The following are the chief points of interest, in giving the subjoined 
history, or rather histories, of this interesting case. 
1. The very large dosage of arsenical solutions. 
2. The extreme tolerance of them by the individual. 
3. Their well-marked beneficial effect upon the growth and the indi- 
vidual. 
4. The complete or almost complete subsidence of the tumors at vari- 
ous times while the treatment was under way, and their ready recurrence 
on suspension of same. 
5. The relative obstinacy of the growths situated on the neck and 
head to treatment. 
6. The evident delay of the ultimate lethal issue, in spite of the 
recalcitrancy of the patient. 
7. That the treatment instituted was original in character, the author 
at the time of its commencement not being acquainted with the writings 
and experiments of Kbbner and others in the same direction. 
The patient, Mr. G. S. H., aged thirty-nine years, native of United 
States, medium height, fairly well-built and nourished, of somewhat 
nervous and anxious expression, was first seen by me at my office toward 
the end of February, 1888. He had at the time a large indolently 
ulcerating tumor situated on the posterior portion of the left thigh, the 
lower portion involving the upper part of the popliteal space; he 
claimed that it had its origin in irritation caused by an uneven and 
broken high stool, upon which he had been accustomed to sit at his 
duties as a clerk in an office; it first commenced as an indurated lump 
with inflamed border, then began to ulcerate, about four months previ- 
ous to his first visit, and had become as I now saw it. He dated his 
earliest noted symptoms back to about a year from the date of visit. 
Recognizing an interesting and probably malignant trouble, I treated 
him a few days with placebos and cleansing applications. The New 
York Dermatological Society meeting of February, 1888, occurring a 
short time after, I presented him there for diagnosis and discussion on 
his case, which is reported briefly, in the April number of that year, in 2 
SHERWELL, MULTIPLE SARCOMATA. 
the Journal for Cutaneous and Venereal Diseases, under the heading of 
" The Society's Proceedings." It was regarded as malignant by most 
of those present, my own opinion being that it was sarcomatous. 
Ablation was recommended by almost all. He would not submit to 
this, and refused even to have a small piece taken out for microscopical 
examination. 
The tumor grew rapidly larger, while the patient still deprecated 
any operative measures, although strongly urged, until, the indications 
of its malignity becoming evident even to himself, he at last yielded, 
and on April 15, 1888, at his own house, I removed the whole of the 
tumor and surroundings down to the fascia, by a nearly circular in- 
cision, the wound measuring four and a quarter inches in diameter, 
the tumor itself at the time measuring three and a quarter inches in 
diameter, so that the zone of slightly involved tissue was well included; 
the wound was cauterized with chromic acid and allowed to heal by 
granulation. Portions of the tumor extending from the free margin to 
the centre were examined by Drs. G. T. Elliott, A. R. Robinson, the 
President of the Brooklyn Microscopical Society, and myself, all coming 
to the same conclusion, that it was undoubtedly sarcomatous. 
The progress of healing of the wound being necessarily slow, he was 
allowed to leave for the country (New Hampshire, his home) at the 
end of May; he remained away a little over a month, returning at the 
end of that time with still a small open sore. During this month's 
absence another small button-shaped and quickly ulcerating tumor had 
appeared on the right thigh just below Poupart's ligament, which he 
absolutely refused to let me excise or take other radical means to 
remove. He still remained inattentive as regards visits, although he 
said he would try any medicine, and begged for it. Later on, in the 
course of three months, a large number of other tumors appeared in 
various regions of the body ; on both nates, sides of chest, over the 
shoulder, on the arms, were quite large ones, all of which developed 
more rapidly than the first in the femoral region, with which they were 
uniform in general appearance and mode of progression, save that there 
was greatly increased rapidity of development everywhere. 
I had given no internal treatment to speak of up to this time, except 
for a short time at the end of February and beginning of March, when I 
tried an active course of mixed treatment which seemed to hasten ulcer- 
ation, and was consequently stopped. 
The same requests, as at first, for instant operation for ablation of the 
growths met with the same fight for delay, so that it was not until he 
became hopeless of any improvement without that course, that he finally 
consented, and on October 7, 1888, he entered Brooklyn Hospital, as 
my private patient, I being then on service, for a course of entirely 
radical treatment. 
I operated on him on that day, he being under ansesthesia about two 
hours. I removed the tumor in the femoral region (it measured two 
inches in diameter) by excision; six other large ones, none being less in 
diameter than a silver dollar; and a number of smaller ones, about 
thirty in all, I extirpated partly by excision, partly by raclage with 
sharp dermal curette; cauterizing all with chromic acid around edges 
of wounds, and thereafter using bandages and dressings of simple 
cerate. I had previously resolved to test the effect of arsenic in full 
doses, and in a cumulative way, having a distinct belief that it would SHERWELL, MULTIPLE SARCOMATA. 
3 
favorably affect his condition, but must own that I was surprised at the 
evident beneficial effect in a relatively short time. I put him, then, 
about thirty-six hours after the operation, on a mixture of four parts 
of Fowler's to one of Donovan's solutions, to commence with eight-drop 
doses of the mixture four times a day, adding daily at least one drop to 
each dose, sometimes more, until I had him taking twenty-six to thirty 
drops four times a day; about that time he would usually, and some- 
times before he reached that limit, show an amount of constitutional 
reaction, which though not as extreme as might be thought, would be 
sufficiently marked to show the danger limit, and the stomach would give 
out a little, so that it would become imperative to suspend the remedy 
for awhile, and give the stomach rest for a day or two, never longer, 
beginning immediately again with about ten-drop doses. 
Many of the small tumors, half-pea sized, or even larger, which I 
had not curetted, disappeared in a very few days, not more than a fort- 
night or at most three weeks after instituting this constitutional treat- 
ment ; all infiltration of the edges and areola dying away where there 
had been infiltration around other tumors, and on the former sites of 
these small tumors an atrophied spot could be felt, such as occurs in 
morphcea or in scleroderma after subsidence of the acute lesion. He 
did steadily well, became able to attend to business in some measure, 
and in December 1888, I first took him to my friend, Dr. A. R. Robin- 
son, who had previously been in consultation with me just before his 
reception into Brooklyn Hospital, for a thorough examination, and 
subsequently took him to the December Session of the New York Der- 
matological Society, when I placed him in evidence as a valuable, not 
to say wonderful, illustration of what arsenic can do in modifying this 
form of kakoplastic embryonal fibrous tissue. He then, with my per- 
mission, took cars for his native place to pass Christmas and New Year, 
with precise orders how to take his remedies, when to leave them off, 
and with most distinct and solemn promises on his part to keep me well 
posted as to his progress, etc. I heard thereafter once or twice from him 
at disconnected times; he evidently fell under influences that were not 
favorable, with one exception, that of Dr. S , a practitioner'of the 
town in which he lived, who used his best efforts to keep him in line, 
but failed; so that from this time I may be said to have lost control of 
the case. 
When I next heard of him he was in the hands of Dr. John B. 
Wheeler, of the College and Mary Fletcher Hospital, Burlington, Vt., 
who kindly furnished the following complementary history : 
" When Mr. H. first came under my care, February 15, 1889, he 
was covered with the sarcomatous growths with which you are familiar. 
They varied in size from one-eighth inch to two and a half inches in 
diameter. He was in a condition of extreme exhaustion, excessively 
hyperaesthetic, so that he could hardly bear a touch without screaming, 
sleeping with great difficulty, and almost devoid of appetite. Under these 
circumstances I thought it best not to begin the arsenic treatment 
which he said had had a very good effect on the growths but a very 
bad one on him, and I therefore put him on quinine, stimulants, and 
morphine, with the intention of building him up and of removing the 
growths as fast as I could. This treatment was continued until May 1st. 
During this time I operated on him four times, at intervals of two or 
three weeks, and removed in all one hundred and seventy tumors. 4 
SHERWELL, MULTIPLE SARCOMATA. 
They were cut out with scissors and the raw surfaces thoroughly burned 
with the Paquelin cautery. Careful antisepsis was observed, but after 
•granulation began the raw surfaces were dressed with balsam of Peru. 
Microscopical examination of the growths removed showed a structure 
fairly typical of sarcoma. Recurrence took place faster than it was 
possible to operate, and the only advantage afforded by operation was 
that the growths were removed when they were small. No recurrence, 
however, ever took place in a cicatrix, except on the scalp, where the 
skin surrounding the growths had become much more infiltrated than 
elsewhere. Everywhere else the wounds granulated well and cicatrized 
quite promptly, the new growths all appearing in the sound skin. 
"On May 1, 1889, as the sarcomata were multiplying rapidly and 
the patient had got into a very fair condition of general health, I began 
to give him the same mixture which I believe you used, one part of 
Donovan's solution and four parts of Fowler's. The dose was at first 
ten drops, t. i. d., but as soon as I found he bore that without trouble, 
the dose was increased one drop every day. He stood this very well 
until doses from eighteen to twenty-five drops were reached (sometimes 
I could get him up to twenty-five, sometimes not above eighteen) when 
his appetite disappeared, his eyelids swelled, and he became nauseated, 
and very nervous and hypersesthetic. The dose was then cut down to 
ten drops, when he would become all right again, whereupon the dose 
was again gradually increased to the limit of tolerance. He took his 
arsenic in this way as long as he was under my care, raising and lower- 
ing the dose according to indications, and also took from one and a half 
to six ounces of whiskey, and from i gr. to 1 gr. of morphine daily 
most of the time. 
"In about four weeks it became evident that no new growths were 
appearing, and that those which had grown since the last operation 
(some thirty in number, some of them one inch in diameter and badly 
ulcerated) were less angry looking and were diminishing in size. By 
the end of June, not the faintest sign of a malignant growth was left1 on 
the man (except the cicatrices showing where the growths had been), 
saving some half-dozen on the face and scalp, which for some reason 
(great vascularity of skin of those parts ?) seemed to resist the arsenic 
with uncommon obstinacy. 
" By the 20th of July, the patient had become so thoroughly poisoned 
with arsenic, swelled eyelids, loss of appetite, strength, nervousness, 
hypenesthesia, and despondency (no diarrhoea) that I became alarmed 
and stopped his arsenic for ten days, at the end of this time his general 
health had improved greatly, but a dozen new sarcomata had appeared 
on trunk and extremities. 
"The arsenic was resumed July 30th, in the same way as before. 
For about a week the sarcomata enlarged until some reached one inch in 
diameter, then they became less inflamed and diminished in size. No 
others appeared. 
" By August 22d several of the growths had disappeared and the 
remaining ones were steadily diminishing. At this time the patient 
became very desirous to go to his home in New Hampshire, and as he 
was in fair condition and apparently able to stand the journey, I con- 
sented to his departure, which he took on that day. My only news 
1 Underlined in original. SHERWELL, MULTIPLE SARCOMATA. 
5 
from him since then is a short note written by his physician the day 
after reaching home, which informed me that Mr. H. had stood the 
journey well." 
The exact date of his demise I do not now remember, but his friends 
informed me that it was about the end of December of that year, it being 
due apparently to neglect of remedies, recurrence, and consequent ex- 
haustion. 
In regard to what I have termed, at the commencement of this paper, 
the points of interest in this case: 
First. While there may be records of larger therapeutic doses used 
than those here given, the time element also being considered, none such 
have come under my notice in my readings. The daily amount of 
arsenious acid was, as will be noticed, about a grain a day at times. As 
regards the mixture, which will be lemembered as being four parts of 
Fowler's and one of Donovan's solutions respectively, I may say that 
I added the latter solution, not for its specific mercurial effect, but as 
an additional and effective absorbent or resolvent agent. 
No doubt as to correctness of diagnosis is probable-the high grade of 
examiners renders that impossible; but should such doubt exist, the 
balance of the larger tumor is still in alcohol in my possession, and is 
at the service of anyone interested in the subject. 
Second. The tolerance, as was evident, was exceedingly marked, and 
the very rapid disappearance of toxic symptoms on cessation of the 
remedy was peculiarly so; in a couple of days, ordinarily, all such 
symptoms, gastric or other, would entirely disappear. This, however, 
I do not think unusual, as a good many patients suffering from psoriasis 
whom I have treated at some time by arsenic in the course of their 
disease, have shown the same ready disappearance of bad effects. 
Third. It is now scarcely necessary to say anything as to the effect 
upon the individual or the tumors; as to the latter the history speaks, 
but as to individual it may be further said that while he was under 
observation the fairly large doses (not those near the toxic mark) 
seemed to benefit and improve nutrition and strength. 
Fourth. The subsidence of the tumors on taking the remedy has also 
been sufficiently dwelt on in the histories, but it would seem important 
to call attention once more to the fact of their extremely rapid recur- 
rence on disuse of the remedies; this was very marked, and seemed to 
be very like a problem in arithmetical progression ; the more tumors 
present, the more rapidly would others develop in other parts, and the 
more readily would ulceration in the larger ones begin and continue. 
Fifth. The relative regional obstinacy in regard to treatment. This 
was noted by Dr. Wheeler particularly, and though not so specially 
noted in my history, was observed by myself. To particularize: At the 
time of operation in the hospital, I purposely left one growth on the neck, 6 
SHERWELL, MULTIPLE SARCOMATA. 
above the collar, in order to better observe its conduct while under con- 
stitutional treatment: precisely that one, and one or two others on the 
scalp, were the slowest to respond, persisting after others had entirely 
disappeared. I have noted this fact before, and in an article read 
before the American Dermatological Association, " Remarks on, and 
Queries as to, the Relative Frequency of Pathological Changes in Moles 
and other Tumors on the Face and Head," which was published in the 
Journal of Cutaneous and Genito-urinary Diseases, January, 1887, I use 
the following words : " There are many other parts of the body, it would 
seem, equally or more exposed to these accidents than the carefully 
guarded face; as for instance the hands, nates, waist, and neck; the two 
latter from constant friction of clothing and other causes. Moles and 
other small tumors are sufficiently common on all parts of the body, but 
it would appear by the statistics given, and by other experiences of the 
writer, that the ratio of further and destructive pathological activity is 
much less in them (that is in all other parts of the body) than on the 
head and face." Further: " The most rational way of solution or 
accounting for the frequency of these growths on the site mentioned is 
probably that it is after all due to the extent, nature, and abundance 
of circulatory nutrition, which must favor hyperplasia in these well- 
supplied parts," etc. 
Sixth. Delay of lethal effects of the disease I shall not dwell upon ; it 
was certainly evident to all having any close connection with the case. 
Seventh. As has been stated, though it may read as a confession of 
carelessness on his part, the author at the time of inception of constitu- 
tional treatment was ignorant of the records of recent experiment of 
others in the same direction. He had, however, been long convinced of 
the inhibitive efficiency of the drug in other malignant affections, notably 
epithelioma, and has been very lately additionally confirmed in this by 
many cases, among which may be cited a recent and marked one of geni- 
tal epithelioma ; a secondary operation having been done, followed by a 
third, to remove immensely involved inguinal glands and tissue. The 
operation was brilliantly and radically performed by one of New York's 
leading surgeons; but all the consulting medical men (at least five in num- 
ber, including myself) decided it was impossible, or almost so, for recur- 
rence not to rapidly take place, and the patient was by general verdict 
given anywhere between three and six months to live. This occurred 
about a year since. Arsenical treatment, at my suggestion, has been 
since employed. The individual is now living and enjoying better 
health apparently than for some years previous. This conservative 
result, I believe, has been largely due to the result of this constitutional 
treatment. 
Dr. H. Kobner's writings and cases came under my observation 
some months after inception of my treatment, but since that had acted SHERWELL, MULTIPLE SARCOMATA. 
7 
so well, I did not feel like "changing horses while crossing a stream," 
and persevered with internal medication. 
It will be noted that Dr. Kobner gave his arsenic hypodermatically, 
which doubtless has its advantages, but also its disadvantages, as caus- 
ing slight wounds and points of irritation. 
I do not see why the conjoined treatment, internal and hypodermatic, 
might not be used with greater benefit than either alone, or at least so, 
where rapid results seem necessary. 
His papers will be found in the Berliner Iclin. Wochenschrift, 1883, 
page 21, under the title of " Heilung eines Failes von allgemeinen 
Sarcomatose der Haut durch subcutane Arseninjection." Also, in 1886 
(ibid., p. 193), there is report of a case shown at a meeting of the 
Berlin Medical Society, under the heading " Vorstellung eines Failes 
von multiplen Hautsarkomen der Extremitaten." 
Dr. Funk, of Warsaw, in the Monatshefte f. prakt. Dermatologic, 
1889, viii., page 19, publishes an exhaustive article under the title of 
" Klinische Studien fiber Sarkome der Haut," giving histories of cases 
of his own in which he had followed Kobner's plan of treatment, and 
a general resume of the subject and writings thereupon. The article 
would serve as a bibliographical index. He recommends, as does 
Kobner, the injection of a recent solution of arsenite of soda, as being 
on the whole the best. 
As I have before said, the union of the internal and hypodermatic 
methods would, however, in my opinion, seem to offer the best future 
therapy.