Epithelioma: 
Its Etiology, Diagnosis and 
Treatment. 
A Paper read before the Ohio State Medical Association, 
held at Akron, Ohio, 
BY 
B. M. Ricketts, M.D., 
Former House Surgeon, N. Y. Skin and 
Cancer Hospital. 
June, 1886. EPITHELIOMA: 
ITS ETIOLOGY, DIAGNOSIS AND TREATMENT. 
A Paper read before the Ohio State Medical Association, held at Akron, June, 1886, 
By B. M. Ricketts, M.D., 
Former House Surgeon, N. Y. Skin and Cancer Hospital. 
Mr. President and Gentlemen: 
There is perhaps no disease which 
causes greater suffering or renders the 
patient’s presence more disagreeable tor a 
greater length of time than that of cancer. 
All tumors which destroy tissue and show 
a tendency to recur after having been 
removed one or more times, have been 
known as cancerous and the least amen- 
able to treatment from time immemorial. 
Authors writing upon this as upon all 
other subjects are inclined to elaborate and 
intensify rather than simplify their thoughts 
and investigations; in general they are too 
much so to be used to an advantage at a 
time when most needed. 
Their productions are looked upon as 
being matter of reference and lie buried in 
indigested confusion in the various chan- 
nels of medical literature. It is their vo 
luminous and expensive character which 
renders them to a great degree inaccess- 
able to the majority of practitioners. 
The finding of trustworthy characteris- 
tics for a clinical conception of this disease 
was not attempted until the time of Bichat, 
Muller and Rokitansky, who clearly defin- 
ed the histological tissue development— 
the last named gentleman describing them 
as fibrous, gelatinous, pigmented, papil- 
lary, epithelial, etc., and who said that 
“cancer con-sisted in the first place of 
nuclei and nucleated cells of the most 
various forms. These existing in greater 
or less abundance afford the elements of 
the cancer juice, and together with an 
interstitial substance, constitute the bulk of 
the cancer.” 
They form the essential, and generally 
owing to their short duration, exuberent 
production and accumulation, “the most 
important heteroplastic constituent of can- 
I cer.” 
The other less essential, though very 
important constituent is (new) connection 
tissue in the form of the so-called stroma. 
He says in addition that the clinical char- 
acter of the growth is an indispensable 
feature. 
(') Parker, who has carefully studied 
this disease, says, “that it is the cause of 
one hundred and twentieth of all the 
deaths throughout the world, and that it 
does not prevail in certain localities, it 
being almost unknown upon the banks of 
the Nile, among the American Indians, 
Hindoos, Egyptians, and the native black 
population of Africa.” 
Upon the other hand, there are certain 
localities and countries where it prevails to 
a greater or less degree, as for instance 
upon the water courses of England and 
Wales, where it is perhaps more common 
than any other locality. 
It is said that Liverpool, England, is 
the centre of such a district comprising one 
hundred square miles. 
I will so far as possible systematically 
arrange the subdivisions that we may con- 
fine ourselves to one particular class of this 
disease, namely, Epithelioma, my object 
being to furnish trustworthy and accurate 
detailed information, at the same time 
avoid speaking of the absolute distinction 
there really is from a pathological view. 
This will necessitate leaving out some 
very important factors but enables us to 
speak more extensively only of the most 
striking aspects. I might say, however, 
that the structure of epithelioma deviates 
less than all others from natural tissue and 
that it is the only form of cancer whose 
origin has satisfactorially been associated 
with previous local disease—constant irri- 
tation being the most common cause. 
(2)“Mr. Shaw speaks of this disease, ap- 
pearing in an issue of thirty years’ stand- 
ing.” 
“Mr. Chalk also mentions a case in 
which he successfully amputated both 
lower limbs of a man in whom bunions 
1. Parker, on Cancer, 1885. 
2. Holmes’ Surgery, Vol. iii., p. 290. 2 
Epithelioma.—B. M. Ricketts. 
after remaining for many years unhealed 
had become affected with epithelial can- 
cer.” 
“ De Morgan cites a case where this 
disease appeared in an unhealed surgical 
wound in the perinaeum three months after 
the section of stricture urethra. 
(')Billroth gives a case where an epithe- 
lioma developed from a fontanel kept up 
for ten years with peas; also of the same 
disease appearing in an ulcer of the foot 
which had existed for years without any 
known cause. 
It was not until 1840 that epithelioma 
was known as a distinct disease. To Ro- 
kitansky alone, who was a member of the 
Vienna school at that time, is due the great 
credit of placing our knowledge of this 
peculiar disease upon a higher plane. In 
our desire to praise this great man we do 
not forget his co-laborers such as Rind- 
fleisch, Klebs, Thiersch, Volkman, Luck, 
Virchow, Waldmyer and numerous others 
that might be mentioned. 
Besides being the first he (Rokitansky) 
has since established greater and broader 
avenues to advancement in this particular 
branch of medical science than any person 
therewith connected. 
He has created within his associates a 
greater ambition and the result of his labor 
has been the stimulant to their exertion. 
Until his time tumors were named 
according to their appearance as lupus, 
serpigo, noli-me tangere, syphilis, fam- 
brosia, ulcus rodens, fungus, cancer, pha- 
gadaenicus, etc. 
We now have the epithelioma of 
Hannover, epithelial cancer, carcinoma 
epitheliale, cancroid or pseudo-cancer of 
Lebert, and scrotal or sweep’s cancer of 
Pott and Cooper, all amounting to the 
same thing and differing from all other 
varieties in being much less malignant and 
always growing in connection with a cuta- 
neous or mucous surface. Virchow calls 
them the semi-cancerous. It is less pain- 
ful and occurs most frequently upon the 
lower lip or lower eyelid. 
Of the 102 cases reported by (-) Thiersch 
seventy-eight were in the region of the 
face, forty-eight of which were in the lips, 
ten on mucous membrane of the mouth, 
four on the extremities, several on the 
naval and one between the shoulders. He 
thinks that the upper lip has an immunity 
against the disease. However Hebra re- 
ports two cases of nodular epithelioma of 
upper lip having been cured. They may 
appear at or near any muco-cutaneous 
junction. 
says that he met with it once 
on the tongue of a boy eighteen years of 
age. 
(2)Kaposi met with epithelial cancer on 
the face of a girl ten years old and in 
another eight years of age. 
It has never been known to have oc- 
curred in the nostrils or air cells of the 
head, and seldom found in the internal 
organs. However the subordinate glands 
may become hard early in the course of the 
disease and increase until finally they be- 
come of an enormous size, break down, 
become ulcerative and involve any tissue, 
even bone, tendon or muscle. 
The average time for it to destroy life, 
as shown by Mr. Stedling’s deductions 
from the records of the (3) Middlesex Hos- 
pital being fifty-three months—longer than 
that of any other form of cancer. 
Among the 10,759 cases of cancer 
treated at the (4) London Cancer Hospital 
from 1852 to 1874, 2,010 were epithelial, 
1,423 males and 587 females. In the 
males 819 were upon the face and lips, 
while there were but 279 upon the face 
and lips of the 587 females. 
Of the 102 cases reported by (5) 
Thiersch, eighty were men and twenty-two 
were women. 
(6) Paget found eighty-six men and 
nineteen women in 105 cases with corres- 
ponding localities. 
Thus the above tables show, as do the 
majority, that this variety comprises one- 
fourth the number of cancers, that it occurs 
oftener in men than women, and oftener 
upon the lips and face than any other part 
of the body. 
1. Billroth’s Surg. Path., p. 694, 1881. 
2. Hebra’s Disease of Skin, Vol. iv., p. 211, 
1875. 
3. Med. Surg. Trans. Vol. xlii., p. 125. 
4. Marsden, Treat, of Cancer, London, I874, 
p. 15 and 16. 
5. Der Epithelial Krebs, namentlich der 
haut, p. 305, Leipsig, 1865. 
6. Paget, Lectures on Surgical Pathology, 
3d Edition, p. 733. 
1. Billroth’s Surgical Pathology, p. 693, 
1881. 
2. Ilebra, Manual Dermatology, Vol. iv., 
1875- Epithelioma.—B. M. Ricketts. 
The means most urgently sought are 
those which will relieve suffering and cure 
the disease. 
But before entering upon this part of 
the subject I wish to mention the various 
classifications which epithelioma have been 
subjected to within the past half cen- 
tury. 
Thiersch seems to be content with class- 
ifying them as superficial or flat and deep 
or infiltrated. 
(’) Kaposi and Hebra have adopted 
that of superficial, deep-seated or nodular, 
and papillomatous. Schuh distinguishes 
them as first, superficial; second, granular; 
and third, warty or papillary, while some 
of the more modern authors have adopted 
the following, which, I think, is the most 
preferable. * 
First, superficial or “flat;” second, 
deep-seated or “infiltrated;” and third, 
papillary or “warty,” (') Billroth supply- 
ing the word “warty.” 
There is still another, adopted by 
(*) Alex. Marsden, which consists in class- 
ifying them as hard, soft, surface, deep, 
warty, and pedunculated, but as this is of 
no special practical value, I will pass it 
without further consideration. 
As the treatment and its results vary 
somewhat in each of the three divisions, 
we will carefully study them separately. 
The superficial or “flat” epithelial 
cancer, is the most common and occurs 
oftener between the fiftieth and sixtieth 
year, and as often in women as in men ; 
appearing as small shining nodules about 
the size of a pin’s head of a pale yellowish- 
white color, or it may start and grow 
as a warty excresence composed of one or 
more waxy nodules, with a disposition 
to excoriate early in its course. As a rule 
there is at first developed a small very 
adherent dry yellow scab, whose removal 
is followed by slight capillary hemorrhage, 
which becomes greater as the process of 
ulceration (which is much slower in this 
variety) progresses, seldom enters the sub- 
cutaneous cellular tissue, may heal in the 
center, continuing to involve the surround- 
ing skin or ulcerate in the oldest part, 
in either instance producing an ulcer vary- 
3 
ing in size, from the sixteenth of an inch 
to many inches in diameter, covered with 
an offensive purulent fluid which was a 
clear sticky odorless serum, previous to 
the beginning of ulceration. 
The edges may be round or irregular 
seldom sharply defined, but nearly always 
hard and everted. 
Its most frequent seat is the eye-lids, 
nose, brow, and cheeks. The next most 
frequent place is the genitals, still it may 
appear upon any part of the body. 
Fuchs calls them the “ Ulcus cancrosum 
vulgare,” (’) but they are more commonly 
known as ulcus rodens or ulcus phagadae- 
mcus. 
They are a form of disease peculiar to 
old persons, and are the mildest and least 
infectious of all cancers. fjGreen says 
that this is owing to the size and character 
of the epithelial elements which render 
them less liable to be transmitted by the 
blood and lymph streams than the cells 
of other varieties. 
In his Boyleston prize essay on the 
anatomy and development of the rodent 
ulcer (Boston 1872) J. Collins Warren 
says; “rodent ulcer is a form of this 
variety of epithelial cancer. Its most fre- 
quent seat is upon the eyelids, and next to 
this upon the sides of the nose. 
When fully developed it consists of 
a circumscribed sharply defined greater or 
less excavation, with a brownish-red or 
purpleish-red dry or scantily secreting 
mamilated surface, the ulcer having often 
a rolled border. Its course is very slow 
but relentless; it invades every tissue with 
which it comes in contact including mus- 
cles and bones. If neglected, great des- 
truction of the parts may ensue, and even 
death from hemorrhage in very advanced 
cases. 
A peculiarity of this form of epithe- 
lioma, is that it is a disease of the upper 
part of the face, occurring usually above a 
line drawn across the face horizontally on 
a level with the alae nasi and the lower 
border of the ears. (4)Mr Jonathan Hut- 
chinson is of the same opinion. 
It is not until the disease has involved 
1. Hebra, Dis. of Skin, 1875, Vol. iv., p. 
202. 
2. Billroth’s Surg. Pathol, p. 689, 1881. 
3. Marsden, Treat, of Cancer, London, 
1874. 
1. Die Geschichte des Ulcus rodens; bie 
Thiersch. 
2. Green’s Pathol, and Morbid Anatomy p. 
160, 1878. 
4. Illustra. Clinical Surgery, vol, 1, fasc, I. 
p, 14. London, ' Epithelioma.—B. M. Ricketts. 
4 
the deeper tissues that any great pain 
or constitutional effects are manifested. 
Thus a superficial cancer may exist indefin- 
ately. allowing the patient to enjoy good 
health. 
When it deviates from its superficial 
character it is no longer of this variety 
but has assumed the characteristics of the 
second variety — deep-seated or infiltra- 
ted,—the most common way by which the 
second variety occurs, although it may 
begin wholly of itself. 
The course of the deep-seated or infil- 
trated cancer is much shorter than the pre- 
ceding one. and accompanied with greater 
suffering and more serious consequences, 
having been known to run its fatal course 
in one year. 
There is a peculiar shrinking of the 
older parts which produces the umbillicated 
condition so often met with, causing the 
edges to become elevated, hard, and of a 
dark bluish-red. They may break down 
and begin to ulcerate early or late in their 
course, the pain increasing with the pro- 
gress of the disease, as does the cancerous 
infiltration. 
Muscles, cartilage and bone may be- 
come consumed, and the glands in that lo- 
cality become enlarged and undergo 
suppuration. 
The third variety — papillomatous or 
warty cancer—and the most common of 
the three—consists of a new growth, vary- 
ing from the fraction of an inch to many 
inches in diameter, having a broad base or 
may be pedunculated; the edges or the 
centre may be either depressed or elevated 
and bleed readily upon removing the scab, 
which sooner or later becomes fissured. 
(’)Kaposi clearly describes it in the fol- 
lowing manner, by saying that “it is hard, 
and its surface is either flat with depressed 
edges, or slightly drawn in at the centre, 
being at the same time dry and covered 
by a thin shining parchment, like epider- 
mis, here and there superficially fissured 
and studded with brown, firmly adherent 
scabs. Or it is superficially ulcerated and 
the surface of the sore covered by granula- 
tions. Or lastly, it appears deeply fissured, 
lobulated or laminated, of a bright red or 
flesh color and oedematous, bleeds easily 
and secretes an offensive ichor, which if 
leit to itself dries up into yellowish brown 
or greenish scabs which incrust the entire 
surface. When it appears fissured or ul- 
cerated comedo-like friable plugs may often 
be squeezed out of it.” 
He continues by saying that a “papil- 
loma is either superficial, its base situated 
in the deeper layers of the skin, feeling of 
the same consistence as the normal skin or 
it is deeply implanted, in which case the 
hard mass constituting it may be felt seated 
deeply on the skin surrounding its base 
and extending for some distance beyond, 
the pedicle of the papilloma feels hard and 
infiltrated. Sometimes its surface appears 
tuberculated and beset with cancer nodules. 
This difference depends upon whether 
the papilloma is developed upon a pre-ex- 
isting epithelioma, since it may at one 
time develop as such from the first, there- 
fore in a previously normal skin, or from 
a superficial epithelioma; the further 
course of a papillomatous epithelioma is 
similar to that of the nodular variety.” 
The only diseases which are likely to 
be confounded with epithelioma are lupus 
syphilis and rhino-scleroma, from which 
a differential diagnosis is comparatively 
easy. 
The treatment, which should be both 
local and constitutional, varies as much in 
this as in any other disease, the age and 
general health of the patient, duration, lo- 
cation and character of the disease must all 
be considered in deciding upon the course 
to pursue. 
That either form of the disease should 
be removed immediately upon its discov- 
ery there is no question, but there might 
be as to how it should be done. 
Superficial cancer is the most likely to 
be cured by any plan of treatment, and is 
claimed by many to be the only form in 
which caustics should be used; there are 
cases where extirpation by means of the 
knife or actual cautery would be more pre- 
ferable and effectual than caustics. How- 
ever, it would be folly to adopt one plan of 
treatment to the exclusion of the other, as 
each has some particular advantage over 
the other. 
Of the many patients operated upon at 
the University Hospital by Mr. Erichson 
few have returned with a recurrence. He 
says that he firmly believes that excision by 
means of the knife permanently cures the 
disease, even in those cases where the lips, 
gum and lower jaw had become involved 
has entirely ridded the patient of the dis- 
ease. 
x. Hebra, Dis. of Skin, vol. iv, p. 209; 1875- Epithelioma.—B. M. Ricketts. 
5 
(')C. Heath has clearly demonstrated 
the efficacy of this plan of procedure. 
Should a superficial cancer of recent occur- 
rence be found upon the eyelid, alie nasi, 
ear or lip of a person under thirty-five or 
forty years of age, the prognosis would be 
more unfavorable than if found upon a 
person above sixty years of age, as the lat- 
ter generally die from other causes before 
the disease has run its course. 
Thus an early operation should be 
urged upon, especially in the young. 
QMr. Alex. Marsden says, “that a pa- 
tient suffering from epithelioma coming 
under treatment at anything like a reason- 
able time from the first attack may in nine 
out of ten feel sure of a perfect restoration 
to health such was not the case twenty 
years ago. 
Although having been brought into dis- 
repute for many years by being left almost 
entirely in the hands of the charlatan, caus- 
tics occupy a very important position as a 
therapeutical agent in the treatment of epi- 
thelial cancer. 
There does not seem to be any litera- 
ture upon this subject that will throw any 
light upon the time of its introduction in 
the treatment of this class of diseases. 
The actual cautery has been used in the 
treatment of chronic ulcer and wounds 
from time memorial, but the caustics which 
we most desire to study are the acids and 
salts which disorganize animal tissue. Sul 
phuric acid when combined with saffron in 
sufficient proportions to form paste makes 
a substance known as the black paste. This 
is used principally by the French and 
offers an excellent caustic. Then there is 
the chloride of zinc paste, made by adding 
one part of zinc (after deliquesence) to two 
parts of starch (canqaius plan). Lendolfi 
has combined chloride of bromine and anti- 
mony with the zinc, made into paste by 
adding pulverized licorice with a lew drops 
of water ; its use has entirely been aband- 
oned owing to its severity. Hebra modi- 
fies Lendolfi’s paste by substituting strong 
muriatic acid for the chloride of bromine. 
This should be used quickly after being 
spread upon linen or lint strips, not be- 
ing allowed to remain on longer than 
twenty-four hours at a time. It is very 
painful, and like all escharotics should 
never be applied over joints, tendons or 
the face. This formula is also made into 
small, sharp-pointed cones, known as 
caustic arrcnvs. They are to be inserted in 
the line of incision made upon and around 
the part to be excised, for instance the 
breast, which sooner or later sloughs off, 
leaving an open wound to heal by granula- 
tion. 
The most desirable zinc paste is made 
in three strengths by adding wheat flour in 
the proportion of one to two, three, or 
four. It destroys tissue in a direct ratio 
with the thickness of the layer applied; is 
the safest and most popular form of zinc 
paste in use. It is known as Fell’s paste, 
having been introduced into England by 
an American of that name, and is the only 
form of zinc paste that should be used 
upon the face, tendons or joints. 
Arsenical acid seems to answer the pur- 
pose better than all other caustics, especi- 
ally when used after the fashion of Mars- 
den, who was the first to use it with an 
equal part of pulverized acaciae made 
into paste by the addition of a few drops of 
water. It is however, used in a milder 
form in the proportion of one to two, three, 
or four. It should be applied after being 
spread upon a piece of lint or muslin cut 
not to exceed three square inches, and re- 
main not longer than twenty four hours. 
It may be used with safety at intervals of 
twenty hours each as long as indicated, 
but never upon a mucous membrane, be- 
ing principally indicated in the superficial 
and papillomatous varieties. Indeed, 
some members of the profession confine its 
use to these two forms. I have, however, 
seen some excellent results obtained from 
its use in the deep-seated or infiltrated epi- 
thelial cancer, absorption being the thing 
to avoid where there is extensive infiltra- 
tion. This may be done by applying it to 
surlaces not exceeding one square inch and 
allowing the secretions which are rich with 
arsenical poison to become absorbed upon 
cotton or lint with occasional removal. Its 
use is indicated and should be adopted in 
the recurrence of any nodule or unhealthy 
granulation until cicatrization is complete. 
This paste especially should be applied dur- 
ing the morning; if allowed to remain over 
night should be closely watched by an at- 
tendant, whose duty it should be to see 
that it is not dislodged or the poison fluid 
allowed to come in contact with the muc- 
ous membrane of either the nose, mouth or 
eyelids, in which case partial, if not fatal, 
1. Erichson, Sys. of Surg., vol. ii, p. 394. 
2. Treat, of Cancer, London, 1874. 6 
Epithelioma.— B. M. Ricketts. 
poisoning might result. The paste and 
lint form a mass which becomes very ad- 
herent and may require the use of poultices 
to remove it. These should be kept as 
warm as the patient can well endure and 
continued until sloughing is complete—re- 
quiring from four to twenty days. Some- 
times better results may be secured by 
thoroughly scraping, afterwards applying 
the caustic. 
The amount of tissue and caustic effects 
may be governed by applying adhesive 
plaster in which a hole is cut to correspond 
with the area to be cauterized. 
There is still another arsenical paste 
known as Mauce’s, composed of white ar- 
senic, cinnibar and burnt sponge, made in- 
to paste by adding water. This, however, 
is not used, having been discarded for 
milder ones. 
Of the many other forms of pastes, I 
might say that none equal the simple zinc 
paste or that of Marsden, the latter seeming 
to have an affinity for new cell growths—- 
their vitality being so low that there is but 
little power of resistance offered as compar- 
ed to normal tissue. 
This being so, the line of demarcation 
is not long in being formed between healthy 
and unhealthy tissue. 
They are to be used much in the same 
manner and with the same precautions. 
One of the latest and most novel forms 
of caustics is found in pyrogallic acid(') 
made in the form of an ointment of five, 
ten, fifteen or twenty per cent. Its appli- 
cation, as a rule, is not attended with 
pain. However, I have had a case under 
my care in which a ten per cent, oint- 
ment caused pain to such an extent that it 
was necessary to keep the patient under the 
influence of morphia. It is a form of caus- 
tic introduced byjarisch, who recommends 
its use for from two to twenty days, as the 
case may require. It is a German idea, 
and should be well rubbed in and kept con- 
stantly upon the lesion ; ihe effects are more 
active and the results more promising if 
the surface is well curetted immediately 
preceding its application—an operation 
which Hebra, Kaposi, Auspitz, Geo. H. 
Fox and Bulkley strongly recommend. 
If necessary, the patient is placed 
under the influence of an anaesthetic, that 
the scraping may be thoroughly done. 
Dr. Broadbent claims to have had ex- 
cellent results in treating epithelioma with 
a twenty-five per cent, solution of acetic 
acid applied three times daily until slough- 
ing is complete; while Mr. Bergeron 
strongly recommends the use of chlorate of 
potash, both internally and externally. 
Escharotics should not be applied ex- 
cept where there is extensive tissue beneath 
the integument, as is found upon the breast, 
buttocks and thighs; even then with the 
greatest precaution. 
Some person has said that the milder 
forms of paste are indispensible in those 
cases of relapses where the disease is ex- 
tensive with great infiltration. 
Dr. Althaus is strong in his belief that 
electrolysis is the thing to adopt, as it is as 
effectual without pain or discomfort. 
(*)Bryant strongly advocates the use of 
the galvanocautery. 
Carbolic, nitric, muriatic, acetic, sulph- 
uric and chromic acids, separate and to- 
gether with nitrate of silver caustic and 
chlorate of potash, are all used to a greater 
or less degree with varying results. 
The use of any cauterant, whether act- 
ual or not, should be followed by warm 
poultices, and subsequently carbolized oil 
dressing until the wound is entirely healed. 
The nose held in the hand of that piece 
of marble statuary erected in the Anatom- 
ical Museum at Bologna to the memory of 
Gasparo Tagliacozzi is of more significance 
to lovers of this art ot surgery than is gen- 
erally supposed by the profession. 
Surely it represents the genius and char- 
acter of a man who spent most of his life in 
earnest endeavor to replace lost parts of the 
human body, namely, the nose, lips, eye- 
lids and ears, as some one has said, not by 
wood, pasteboard, silver or gold, but (as 
was then at least currently believed) by 
true, veritable flesh. 
It was not until the year 1597 that he 
explained to the people the methods by 
which he accomplished such great results. 
This was satisfactorily done by a work pub- 
lished by himself, entitled “De Chirurgia 
Curtorum per insitianum.” It was the be- 
ginning of a new era in the art of plastic 
surgery. 
Transplantation of tissue goes back to a 
high antiquity, the Egyptians and Hindoos 
having known how to restore a lost nose or 
ear. 
This art necessitates the use of the 
1. Cincinnati Lancet-Clinic, July 11, 1885. 
2. See paper with cases, Lancet, April 4, 1874. Epithelioma.—B. M. Ricketts. 
7 
knife, which is so frequently indicated in 
the deep seated, infiltrated or recurrent 
cases, the excised portion being replaced 
by a healthy piece of skin taken from the 
forearm or hand, with the pedicle attached 
in the manner set forth by Tagliacozzi, 
which consists in raising the skin so that a 
double edged knife may be passed through 
without cutting the subjacent muscular tis- 
sue. Oiled cotton is placed in the wound 
and allowed to remain four days, after- 
wards renewing daily until suppuration oc 
curs, when the flap thickens and the edges 
become encrusted it should be divided at 
the upper end, taking in all about fourteen 
days before it can be adjusted. (’) 
Garritson speaks in praise of this opera- 
tion, adding that he has accomplished most 
satisfactory results. 
Noyes and Knapp strongly advocate 
the use of one or more sliding flaps espec- 
ially where the ali nasi, eyelid, ear or lip 
are involved, they being the first to intro- 
duce the method into this country. (2) 
Union by first intention can only be se- 
cured by the greatest care in coapting the 
edges, which should be cut sharp and dis- 
tinct, the result being more favorable when 
conducted upon the principles of asepsis 
throughout the entire operation, care al- 
ways being taken to carry the line of incis- 
ion as far beyond the lesion as possible, 
that all chances of cutting diseased tissue 
might be avoided. 
Should a failure be made in securing 
coaptation, or there be left as a result of the 
operation a surface to heal, by granulation, 
skin or sponge grafting may be resorted to 
with most agreeable results, after granula- 
tion has sufficiently taken place. 
It should especially be resorted to in all 
such operations upon the face or hands, 
these being localities where the deformity 
resulting from the contraction by the form- 
ation of cicatricial tissue would be more 
objectionable. 
Deformity is relieved to a great extent 
and the length of time for recovery much 
lessened by the use of either skin or sponge 
grafting. 
The former may be done successfully 
by placing small sections of skin taken 
from the arm or thigh by means of a sharp 
pair of scissors--or what is still better, a 
sharp razor—upon the surface and kept in 
position by means of rubber tissue and 
bandages. 
The tissue should be moistened several 
times daily by pure carbolized olive oil and 
should be the only part of the dressing al- 
lowed to come in contact with the grafts, 
the whole not to be disturbed for three or 
four days. If the pus is antiseptic their 
growth will not be interfered with by its 
presence; if in excess free drainage should 
be made. 
Some prefer to spread the epithelium, 
after being cut very fine, over the granulat- 
ing surface, claiming equal results. I my- 
self have never practiced this method, 
having had such excellent results with the 
larger sections, to the size of which there is 
no limit. 
Where a single graft is indicated of any 
very great size, say over one-half inch in 
diameter, it should be cut one-third larger 
than the surface to which it is to be applied, 
immersed in hot water, allowed to shrink 
to its fullest extent, adjusted with edges 
overlapping, and treated with oil dressings. 
Sponge grafting is more recent and still 
a greater novelty, and possescs a few ad- 
vantages over tKe former, especially in the 
treatment of chronic ulcers of great size. 
The sponge should be thoroughly ster- 
ilized by first boiling and allowed to remain 
in a five per cent solution of carbolic acid 
or bichloride of mercury in the proportion 
of one to two or three thousand, and very 
thin sections made with scissors, varying in 
size, should be placed upon the surface 
and treated with the same care and precau- 
tions as in the former. Its meshes become 
filled with capillaries and correspond to the 
connective tissue, afterwards become ab- 
sorbed and pass off with the product of 
waste and repair. 
Since the introduction of cocaine, pa- 
tients need not dread the suffering from 
either the operation or the effects of chloro- 
form or ether. Its use has added one 
grand step in advance of anything hereto- 
fore offered, as it enables us to secure an 
early operation, which before would have 
caused more or less suffering or necessitated 
the use of an anaesthetic, a thing which 
too often causes the patient to postpone un- 
til it is too late an operation which would 
have been beneficial, if not entirely ridding 
it of the malady. 
1. For further particulars see Holmes’ Surg- 
ery, vol iii., p. 622; System Oral Surgery, Phila: 
1873, also, Phila. Medical Times, Se tember 25, 
1880. 
2. See Arch, fur Ophthal., xii., Arch of Op- 
thal. et Otol., I. 1 and 2.” 8 
Epithelioma.—B. M. Ricketts. 
One-half of a drachm of a four per cent, 
solution of hydrochlorate of cocaine will 
render the patient exempt from pain if sub- 
cutaneously injected in the field of opera- 
tion a few minutes previous to the applica- 
tion of caustics, the use of the knife, actual 
or galvano cautery. 
Local anaesthesia can also be produced 
by the application of salt and ice, but there 
is great danger of carrying it so far that un- 
ion by first intention cannot be obtained, 
indeed, it is many times followed by 
sloughing of the immediate parts, causing 
the wound to heal by granulation, thus 
producing an unwelcomed cicatrix, besides 
there is more or less pain attending the use 
of this remedy. 
Special attention should be given to the 
general condition of the patient in the way 
of diet, tonics, fresh air and out-of-door 
exercise. Some form of iron, mercury, or 
arsenic, alone or in combination with some 
one or more of the vegetable tonics, will 
generally answer the purpose. 
According to Mr. Erichsen, epithelial 
cancer may recur in three distinct ways: 
First, local reproduction. 
Second, neighboring but not local re- 
production. 
Third, immediate recurrence. 
In either case rendering the prognosis 
unfavorable in proportion to the extent and 
number of times of recurrence. 
More energetic and radical treatment 
should be adopted upon each return of the 
disease, the plan of procedure being left 
entirely with the operator in each individ- 
ual case. 
53 E. Fourth St. 
CINCINNATI : 
Reprint from The: Cincinnati Lancet-Clinic, June 12, 
1886.