|'Secret' predates Mohs method|
Frederic Mohs is credited with developing in situ chemosurgical technique that set the stage for today's fresh-tissue Mohs surgery. However, the now-famous doctor may owe a debt of gratitude to a lesser-known figure, who in the late 1800s developed a "secret" escharotic substance that eventually was used to treat more than 70,000 cancer patients.
In the beginning, Perry Nichols might not have appeared much different than numerous other "irregular practitioners," many offering home-brewed remedies that had little, if any, basis in science. But based on early treatment successes with his mysterious milky liquid, which in retrospect bore similarities to the dark zinc chloride paste that made Mohs famous, Nichols went on to found a series of clinics that culminated in a 200-bed facility in Savannah, Mo.
Derided by American Medical Association investigators as a "quack" and an "old rascal," Nichols was a benefactor to the community and possibly, even an influence on the more famous proponent of escharotics, according to Gary A. Dyer, M.D., associate clinical professor of dermatology with the University of Missouri at Columbia.
"I secretly wonder, deep down, if Mohs didn't have a look at one of Nichol's yearbooks, and it may have given him an idea," said Dr. Dyer, a dermatologist and dermatopathologist who practices in St. Joseph, Mo., just 13 miles from the city of Savannah, where the Nichols Sanatorium had its greatest success.
Dr. Dyer has spent the past two years piecing together a history of Nichols, interviewing nurses who worked in his institution, and scouring medical archives and local historical records. He has monitored eBay and Internet booksellers for surviving copies of yearbooks Nichols wrote touting his methods, patient testimonies, and cure rates. The yearbooks, titled "Cancer and Its Proper Treatment - The Value of Escharotics," were published starting in 1909 or earlier.
Nichols' method of chemosurgery The contents of Nichols ' escharotic mixture had been a carefully guarded secret , described as a " double compound " ( two main ingredients ) that was " about four times stronger than chloride of zinc or the arsenic of Marsden ' s Paste."
Nichols' chemosurgery method, according to Dr. Dyer, was to make an adhesive plaster dam around the rim of the lesion, lay down cloth strips on the lesion, and apply the liquid escharotic to the cloth. After making pinpricks with a sterile needle, he applied salve for occlusion. This preparation was left in place for a period of time, depending on the lesion (a few hours for skin, perhaps three to four days for breast cancer). The tumor would separate, and a curet was used to clean out the bed. If clinical evaluation revealed residual tumor, the patient would be retreated; otherwise, a poultice was applied and the treated area was allowed to heal. Some patients were offered plastic repair (at no additional charge, at least in the earlier years of practice).
There were no careful studies of the Nichols technique. If Nichols' yearbooks are to be a guide, the escharotic technique had a 75-percent cure rate for all patients accepted (the sanatorium refused to treat patients believed to have no chance for cure). However, this rate was measured using methodology that seems quite lax by today's rigorous standards, and was based largely on reports from nurses or cards sent in by former patients. What's more, the "cure rates" lump together all cancers treated, regardless of diagnosis as skin, mucosal or breast cancer.
Nichols' early treatment successes - and his keen business acumen - led him to open the Nichols Sanatorium, a successful and well-known practice that drew patients from every state and several foreign countries. The practice, founded in Iowa, moved to South Dakota and finally to Missouri in 1911, where it survived until 1956, more than 30 years after Nichols' death.
It was in 1895, at age 32, that Nichols, already a successful farmer and real estate agent, first learned of escharotic treatment of skin cancer from two doctors practicing at an Iowa clinic called the Cherokee Sanatorium. After talking to patients convinced they were cured, Nichols set to work on his own escharotic formula, which he kept secret. In 1896, he spent time working with the same two physicians, and claimed to have treated 40 to 50 patients successfully. By November of that year, he had opened his own practice. Hampered by the lack of a medical degree, he hired a physician in 1897, and pursued his own M.D. degree, which he received from the University of the South-Sewanee in 1901.
Sideline becomes main business Nichols moved to South Dakota intending to open a general medical practice. However, his sideline of escharotic cancer treatment quickly became his main business. In 1905 he was recruited to the city of Hot Springs to head an 80-bed sanatorium.
In 1911, a branch was opened in Excelsior Springs, Mo., and a year later, Nichols was recruited to Savannah, Mo., a location he liked for its central location, available land, and good transportation, including an interurban railway to bring patients to and from St. Joseph. It was here that Nichols' practice thrived, and in 1924, construction was started on a new brick building that had at least 200 beds.
Nichols became ill and died of congestive heart failure in August 1925, but the clinic didn't close until 1956.
Dr. Dyer's review of two surviving record books from after Nichols' death, covering the period from July 1931 to June 1948, showed that the facility was averaging only about 70 surgeries a year. The Nichols Sanatorium closed in 1956, and soon after the Sisters of St. Francis moved in and started a nursing home.
What was in it? A 1933 article in the Journal of the American Medical Association revealed that Nichols' escharotic mixture contained zinc chloride - like Mohs' paste - and butter of antimony (antimony trichloride). Interestingly, in a skin pathology and treatment textbook published in 1895, Kaposi described a "modified Landolfi's Paste" consisting of zinc chloride and butter of antimony.
"Nichols may not have wanted to reveal the contents of his escharotic because it would be obvious that it was a very common combination," Dr. Dyer said, noting that Mohs' paste was also a mixture of two escharotic agents: zinc chloride and bloodroot.
Nichols needed a pathologist In the end, Nichols' firm rejection of pathology may have kept him from a more prominent position in medical history. Whereas Mohs championed biopsy, Nichols wrote in 1918 that cutting out a section and sending it away for examination "endangered the person's life through delay ... (and) next ... by aggravating and stimulating the malignant growth."
"The way I see it, if Nichols had a pathologist on board and they believed in doing biopsies, that would have put to rest critics saying he was treating things that were not skin or breast cancer," said Dr. Dyer. "And having a pathologist, he would have eventually seen the agent was fixing the tissue, and possibly could have made the discovery that Mohs made later."