ride of zinc for cancer of the lip, or of mucous membranes, on account of danger of poisoning by absorption. The fact that the paste can be applied to the healthy skin without producing but very little destructive results shows that it has an elective action for diseased tissue. It acts quicker and with less pain than the chloride of zinc. To my mind Marsden's paste is preferable to all other forms of caustics, and may be regarded as almost a specific for skin cancers if seen early. The wound left should be treated as in the case of the chloride of zinc. If the tumor is large or the wound does not heal kindly, in a reasonable length of time, a second, or even third, application of the paste should be made.

To apply these caustics successfully demands a certain amount of experience, which any one can acquire after applying them two or three times. The greatest cause of failure in their use is the neglect to treat the case energetically until thoroughly satisfied that all diseased tissue has been destroyed.

DISCUSSION ON DR. MORGAN'S PAPER.

Dr. L. G. Hardman, Harmony Grove: I have been very much interested in Dr. Morgan's paper, and I have thought for some time about caustic applications in the treatment of cancers of the skin. It has been my experience in removing cancers with the knife the great majority of them have returned. We find this to be the case very frequently, that patients come to us for treatment who object to the use of the knife, go away and are treated by so-called cancer specialists with success. I have been impressed with the results of these men in treating epithelioma or cancers of the skin, and it has occurred to me for some time that caustic applications in cancers of that kind are certainly preferable, for the reason that in the use of the knife, after the cancer is removed, as a rule, we have

enough flap left so as to get immediate union. In that way, if there are any cancerous cells, or whatever the cause of the cancer may be, whether a cell or a germ, it is left to take on some action, since with the use of caustic applications, either from the inflammatory action set up by them, or the direct effect of the caustic itself, it seems the cancerous process has been changed into a healthy action, and instead of the disease continuing we have a healthy condition brought about, and when the wound has healed we have normal tissue outside of what cicatricial tissue has been produced by the escharotic. For that reason, I have been very much interested in the doctor's paper, and I think the profession as a rule have done themselves injury by discarding escharoties in the treatment of malignant diseases of this character. I heartily indorse his views, and wish to compliment him on the thoroughness with which he went into the description of the different kinds of tumors, namely: malignant and non-malignant tumors.

Dr. V. D. Lockhart, Maysville: I am especially interested in the subject under discussion. I have seen a few cases of cancer. A few years ago there was an irregular practitioner in our section of the country who professed to cure cancer, and he told me how he made up his paste, which consisted of rye-flour and chloride of zinc in the proportion of two parts of the flour to one of zinc. I had an opportunity of applying this paste in two cases. It produced an active inflammation, but succeeded in removing the growth in both cases. It is five years since the first case was treated, and the other was treated about twelve months ago. A clean granulating surface was left which healed kindly in both instances, with no return of the disease. I have not tried the Marsden paste, but expect to give it a trial as soon as an opportunity presents.

Dr. Bernard Wolff, Atlanta: I wish to express my entire agreement with what Dr. Morgan has said with refer

ence to integumentary cancer. My own experience has been chiefly limited to the treatment of superficial epitheliomata of the skin. I think the ideal treatment for incipient epithelioma of the skin is Marsden's paste. It will remove the cancerous nodule in its entirety. The malignant new growth is converted into an open ulcer which readily heals. In incipient epitheliomata caustics, especially Marsden's paste, are vastly to be preferred to the knife. The usual formula for the paste is a drachm of arsenious acid, 20 grains of cocaine, and 2 drachms of powdered gum arabic. The cocaine is quite sufficient to mitigate pain. My plan is to freshen up the epithelioma by means of the curette until a raw surface is secured, then smear the paste on a piece of lint of appropriate size, and apply it to the freshened surface; allow it to stay in contact twenty-four hours, then remove it and curette the slough that has resulted from the coagulating influence of the paste. Then reapply it. After two applications the lesion is practically removed, and then the part is treated in the ordinary way. Of the various pastes I have used, and I have had. quite a large experience in the treatment of these cases, I am decidedly partial to Marsden's paste in this class of cases, and I think my experience agrees with that of Dr. Morgan.

Dr. J. H. Shorter, Macon: The subject which Dr. Morgan has dwelt upon in his paper is an interesting one. It shows us that there is a difference in cases in the chance of return of a malignant growth, according to the locality of the body in which it is situated. I was struck with that fact some years ago when I published a translation of a report of a series of cases in which the malignant disease involved the external portion of the eyeball, generally at the sclero-corneal junction. There were about thirty cases altogether, and I was impressed with the extreme curability of sarcoma in this region. Out of the whole number only one

terminated in total loss of the eyeball, but did not cause death, and some of the cases were followed for ten years or more after treatment without manifesting a return of the disease. On the contrary, diseases of the orbit back of the eyeball, or intraocular malignant troubles, are almost certain to recur.

Dr. M. B. Hutchins, Atlanta:

I think Dr. Morgan has obtained some very excellent results with his caustic applications, and personally I wish to thank him for the paper he has given us regarding the pathology and treatment. I believe Dr. A. R. Robinson, of New York, was the first physician in this country to work out the subject of pastes and caustics and their effects upon cancerous disease of the skin. He has written a great deal upon this subject, and claims to have secured such results, as Marsden did before him, with the paste and caustics, as could not be obtained with the knife. At one time I was tempted to become a complete convert to Robinson's method of treatment, but from increased experience I have come to believe that it will not do to consider that all of these cases of superficial epithelioma must be treated by strong caustics, or any special kind of strong caustic, which is a very painful method of treatment, in order to destroy the growths.

There is one feature in connection with the treatment of epithelioma which is of paramount importance, and that is to remove all of the diseased tissue. If the physicians, who have had failures with the knife in the treatment of these cases, had continued to use the knife and followed it cut more thoroughly by going just a little farther, or beyond the diseased area, then filling the wound either by skin grafts, skin sliding, or a plastic operation, I believe they would get as good effects from the use of the knife as from caustics, in many cases.

As regards the action of the inflammation in destroying

the cancer cells, as is claimed by some, and, understand, I use caustics more than I do the knife in these cases—if the inflammation does destroy and cut off the little infiltrating cells and kills them, why have the experiments of Coley with the erysipelatous streptococci and the bacillus prodigious so utterly failed? They must produce some inflammation. In ordinary cases of epithelioma of the skin I prefer largely the use (under proper cocaine anesthesia) the solid stick of caustic potash, and have obtained good results with it. I have also obtained good results with the Paquelin cautery, as well as with the use of Marsden's paste, and yet I have seen every one of the methods fail, bringing us back to the point that I mentioned a short time ago, namely, of not getting, or removing, all of the disease. It seems to me that the question of inflammation does not explain the whole thing. I think it is just the important point of going far enough with the caustic, cautery, or any of the applications which are used. Caustics are not wholly under your control, and you get a certain amount of destruction that you do not aim for.

One serious objection to Marsden's paste is the length of time it must be left on the surface, and the pain which it produces. You may, of course, have cocaine in your paste, but after a while the cocaine will lose its effect, and the patient then suffers. In the case of an old woman, I gave her a hypodermic injection of morphine, one-half grain, and to all intents and purposes she was dead for the next twelve hours, and I could continue the use of Marsden's paste on her nose for that length of time without causing pain. I do not wish to be understood as condemning pastes and plasters altogether, but I do not think we should consider them the only method of treatment in these cases. If we have cells which have become separated from the original epithelioma and have passed into the lymph spaces and the spaces behind are practically closed up, the caustic does