_On the Cancerous Inflammation._
The cancerous inflammation generally comes in slowly, in some glandular
part, which becomes rather harder, and somewhat larger[106], than it
ought to be; but the pain, for the most part, at first is trifling.
By degrees, both the hardness and swelling increase, and a pain, like
the pricking of needles, is felt in the part. This pain, after some
time, becomes more violent, darting through the whole of the gland,
and leaving a sensation, as if the part had been rudely wrung or
twisted. The tumor still remains moveable under the skin, which is
of the natural colour; but when the disease has continued a little
longer, a greater degree of inflammation takes place, and adhesions
are formed betwixt the skin and the gland, or the gland and the parts
below, at the same time that the pain becomes more continued. The
skin now becomes puckered, or drawn inward, and of a dirty or leaden
hue, which in time acquires more of the red, but is never of a bright
colour. The veins are varicose, and the tumor is, with difficulty,
moveable. When the skin becomes red, we may be able to discern a
superficial fluctuation, which proceeds from part of the gland forming
an abscess[107]. This at last bursts, and discharges a thin yellowish
matter, which frequently oozes out in very considerable quantity; the
orifice enlarges, and the sore penetrates, for a little way downward,
pretty rapidly, and the edges become hard, and overlap a small part
of the disk of the sore; but, soon after this, a fungus rises up; and
although, in some places, the ulcer may become deeper, yet its chief
progress is laterally.
[106] Although the affected gland becomes rather larger, yet the
surrounding cellular substance sometimes diminishes, and the
neighbouring glands are rather contracted, in which case the part seems
to be shrunk.
[107] This abscess sometimes, though very rarely, occupies the whole of
the gland, but oftener only a part of it; and if the gland be large,
there are sometimes several abscesses, of considerable size, which form
unconnectedly with each other, and burst separately.
The cancerous ulcer increases more or less rapidly, and is soon
attended with a burning pain; the surface is unequal, excavations
appearing in some parts, whilst in others a fungus rises up. The
colour is brown, but glistening or fiery. The granulations very soft
and indistinct. A thin ichor, of an abominable fœtor, is discharged in
great plenty, mixed with blood; whilst, in many parts, small pellicles,
like lymphatic exsudations, cover the sore. The surrounding skin is of
a dark purple colour, and the adjacent parts very hard. The margins,
which at first were overlapping the sore, in the course of a few days
are uniformly elevated, and frequently retorted and unequal, as if they
had been bitten by an animal; and over these the fungus frequently
shoots or protrudes, so that the sore assumes the appearance of a
cauliflower. This ulcer bleeds a little upon the slightest touch,
so that at every dressing the cloths are generally bloody; but, at
times, this bleeding is more alarming, proceeding from the bursting
of the diseased veins. These hemorrhages are, in some instances, very
frequent, and reduce the patient to the greatest weakness. Sometimes
they suddenly relieve the unhappy persons from all their woe.
Some time after the abscess forms, and frequently before ulceration
takes place, the neighbouring lymphatic glands swell, and become
affected with a similar action, and follow the same course with the
original sore; only in them the progress is generally more rapid.
After ulceration takes place, sometimes before it, if the abscess
be considerable, hectic fever takes place; the countenance becomes
sallow and unhealthy; the pulse quickens, and becomes small and sharp;
the strength fails; night sweats come on, and colliquative diarrhœa
hastens death.
The parts in which cancer most frequently appears, are the under lip,
the breasts of women, and the testicles of men: But there is no one
part of the body in which it may not occur, although most frequently it
is, in its original attacks, confined to secreting glands.
In the breasts, parotid glands, and some other conglomerate glands,
the disease begins as has been described; but on the skin, and in some
other parts, the progress is somewhat different. The skin, particularly
that of the face, is apt to have a small chronic pustule formed on it,
by the inflammation of one of the sebaceous glands, which, by degrees,
becomes harder, firmer, and more elevated. Soon afterwards, it becomes
rough, and of a warty appearance: It then ulcerates on the surface.
This is covered with a scale or scab, which repeatedly falls off, and
forms again upon the part, until it assume the appearance and character
of the cancerous sore. But, more frequently, the disease is not allowed
to follow this progress, the wart either being rubbed off accidentally,
or removed by ignorant persons. The part then forms a superficial
ulcer, which is slightly hollowed. It is of a glistening flabby
appearance, and the margins are hard, tumid, and a little turned back:
But after the disease has continued some time, the flabby appearance of
the sore is converted into fungus. We may, therefore, from this, and
other cases, conclude, that cancerous ulcers, which are formed without
previous abscess, form fungus more slowly than those which are formed
with them.
When the lips become cancerous, there is generally first perceived
an indurated lump, of greater or less bulk. The skin over it becomes
tender, frets, and is covered with a scurf or scab, which gradually
becomes elevated. Part falls occasionally off, but it is soon replaced.
This by degrees extends itself over the prolabium, and, after some
time, falls off entirely, leaving the part with all the common
characters of the cancerous ulcer. The pain is burning.
When the testicle becomes cancerous, it sometimes follows the common
course of cancer in other glands, beginning with hardness and shooting
pain in some part of the testicles or epidydimis, which gradually
forms an abscess, and ulcerates. But, at other times, soon after
the testicle becomes diseased, an effusion takes place within the
tunica vaginalis. In this case, the disease of the testicle becomes
complicated with hydrocele. It is distinguished by our feeling the
hardness of the epidydimis behind, or the hardness and inequality of
the testicle, when the water is drawn off. It likewise, after some
continuance, becomes more painful than a common case of hydrocele. If
the testicle be not extirpated in due time, the cord becomes hard and
swelled, and comes to ulcerate.
Cancer in the penis generally begins by a kind of warty tumor, and
follows the course of cancer in the face. Sometimes the penis becomes
just like a cauliflower, a large fungus extending from its ulcerated
extremity.
The uterus, in elderly women, is very frequently affected with
cancer[108]. It begins with a feeling of weight and uneasiness in the
lower part of the belly, and the natural discharge of the parts is
increased, so that the disease passes for fluor albus. By examination,
however, we may generally discover a hardness, and sometimes an
inequality, about the os uteri, and may discover the uterus to be
unequally enlarged. After some time, ulceration takes place, and
matter, mixed with a bloody fluid, is discharged. Occasionally,
considerable hemorrhages take place, which are not unfrequently
confounded with menorrhagia; but it may be distinguished by the
continued discharge of a bloody sanies during the intervals of the
hemorrhage; by the continual pain, and especially by our feeling the
projection of the os uteri into the vagina, in some places hard, and
in others soft, but rough, which shows ulceration. After some time,
the glands about the vagina swell; and that canal, in many places,
becomes considerably straitened. Hectic terminates the sufferings of
the patient. On opening the body, we find the uterus generally though
not always, considerably enlarged, with abscess and ulcers in different
parts of its substance. These ulcers, as well as those of the ovarium,
and, so far as I know, every gland in the internal cavities of the
body, have a less tendency to fungate, than cancerous ulcer on the
surface of the body.
[108] It has been said, that genuine cancer is very rare in the uterus,
and that the cases which pass for such are phagedenic. But although the
uterus may be affected with scrophulous inflammation, and phagedenic,
as well as some other specific affections, yet it must be admitted,
from an examination of cases, that the uterus is very frequently
attacked with true cancer. Its substance is found enlarged, hard, and
containing cancerous abscesses in different parts.
When inflammation attacks any organ, or part of the body, and leaves
a chronic tumor, this may assume, as will afterwards be mentioned, a
new inflammation, and may become affected with cancer; though it more
frequently happens, that it assumes the pseudo-cancerous action. The
symptoms and progress of cancer are much the same here as in the breast.
When the eye becomes cancerous, it, unless the disease begins in one of
the glands, such as the lachrymal, or those of Meibomius, is first of
all affected with simple inflammation, which destroys the whole texture
of the eye, and makes it of a different structure, rather resembling
a confused mass than a well organised body. The lucid cornea becomes
opake, and protrudes; the eye enlarges, is affected with a violent
deep-seated pain, and at last bursts, generally on the apex: From this
a fungous substance protrudes, which manifests all the symptoms of the
cancerous ulcer, and in a short time arrives at a great size.
When the nose becomes cancerous, the disease either begins in the
outside, with a small tumor or wart, as in other parts of the face, or
within, by a firm and somewhat painful polypous projection, which frets
on the surface, and soon assumes the cancerous ulceration.
The diagnosis of this disease is of the utmost importance; because
if we mistake cancer for some other disease, we not only neglect the
proper practice, but frequently are led to prescribe remedies which
do infinite harm. If, on the contrary, we mistake another disease for
cancer, we neglect the necessary means of cure, and may even be led to
extirpate a part which might be easily cured by gentler treatment.
Cancer may be confounded with scrophula, syphilis, and some other
affections, which have received no particular name.
There is an affection[109] which begins like cancer, by a hard
schirrus, either of a gland, or still more frequently of one of the
chronic tumors, which has been already mentioned as succeeding slow
inflammation. This remains, for a considerable time, hard, and free
from pain, and there is no puckering of the skin over it. By degrees,
some part of the surface becomes of a purple or livid colour, and
ulcerates. This ulcer remains long superficial; the edges are hard and
rounded; the discharge is thin; the surface is glossy, and no distinct
granulations can be seen; the pain is slightly smarting, but not
burning, and instead of being fungous, the sore is slightly hollowed
out below the level of the surrounding skin. By the continuance of
this affection, the gland is apt to shrink and diminish in size;
and generally where this takes place, the sore contracts and heals
with a very puckered unequal cicatrix, having, in some places, a
thick dark coloured scab covering it[110]. The neighbouring glands
become affected; but they are soft, and rather resemble the spongoid
inflammation than schirrous hardness: But I have never had an
opportunity of observing them proceed the length of ulceration. If the
continuance of the sore be long, the constitution is affected, and the
patient becomes hectic[111]. This kind of ulcer may be distinguished
from cancer, if we attend to the absence of the fungous, and peculiar
appearance of the cancerous sore, and the want of the burning pain:
But, before ulceration takes place, the two diseases may be confounded;
because there are no certain characteristics of schirro-cancer.
[109] To this specific affection, we may give the name of
pseudo-cancer, for want of a better designation.
[110] Of this nature was probably the ulcer mentioned by Mr. Wiseman,
at least if we may judge from his very short description: “It had eat
deep into her left breast, and was fixed to the ribs, but not with much
pain. In progress of time, the lips inverted, and united, as it were,
and lay covered with a crusty scab; the humour in the mean while spent
itself upon the nerves, &c. She lived long, and, in her latter age,
tolerably healthful.” Chirurg. Treatises, Vol. I. p. 165.
[111] Extirpation is the only certain cure of this disease; and it is
at all times the quickest and the best; but, by eschoritics, we may
sometimes procure cicatrization, at least if the gland have shrunk, and
most of its substance been destroyed.
This disease may attack the uterus, and is very apt to be confounded
with cancer; nor is it easy to distinguish them, as the parts are
unseen. There is never much enlargement. The ulcer is pretty smooth,
and the margins circular, hard, and glabrous. The pain is not very
considerable. The discharge is thin, copious, and of a yellowish
colour, but seldom bloody, unless when the disease has continued very
long.
The spongoid inflammation has been considered as cancerous by those
who have seen it; but the distinction betwixt the two is sufficiently
obvious: The one begins with a spongy elastic tumor, the other with a
firm hard lump.
Scrophula may be mistaken for cancer, when it appears in one of the
secretory glands, such as the breasts; at least as long as it remains
without ulceration. But the tumor generally enlarges more rapidly than
cancerous tumors, at least such as are not very painful. It is pretty
soft and doughy, the pain is inconsiderable, and we may generally
perceive the marks of a scrophulous habit. When ulceration takes place,
the opening is, for some time, sinous, and the matter discharged is
curdy, and without fœtor. When the ulceration extends along the skin,
it has not the fungous appearance of cancer, but the aspect of a
scrophulous sore, and the gland below appears sloughy. The pain is not
very considerable, and is not the burning kind.
Scrophulous inflammation may also attack the uterus, bladder, and
any of the internal organs. The uterus and bladder become thickened,
and contain abscesses in different parts, which point on the surface
of these viscera. They are filled with a thick white cheesy-looking
matter; and when they burst, they produce ulcers, with a foul surface,
and having the margins notched, and lying for a considerable way over
the disk of the sore.
The distinction betwixt cancer and the venereal ulcer is so very
striking, that it is scarcely possible for these diseases to be
mistaken for each other, if the discriminating marks of each be
attended to. The cancerous sore is always dark coloured; the surface
fiery, yet of a fungous nature; the discharge foul, and of an
intolerable smell; and the bottom and surrounding parts are hard and
painful. If there be not an open running sore, the part is covered with
a dry elevated scab, of a dark colour; the skin around this is livid,
and the neighbouring parts indurated. The base of the venereal sore is
much softer, the discharge is of a different nature, and its aspect so
peculiarly unlike the cancerous sore, that it is impossible to confound
them[112].
[112] It is to be regretted, that some who belong to our profession,
reason upon the nature of ulcers, not from appearances and
characteristic marks, but from the patients manner of life, or the idea
which they have formed of the country whence they come. I remember two
instances of people who came from the Hebrides, the one with a cancer
of the lip, the other with a cancerous ulcer on the neck, both fungous,
and possessing the burning pain, and every character of cancer; but
as the sibbens unluckily prevailed in that country, it was thought
that the patients might have received this infection, and accordingly
were, by a full consultation of surgeons, condemned to undergo a course
of mercury. The lip was, in three days, greatly worse; the mercury
was omitted, and the patient cured by an operation. The sore on the
neck was instantly exasperated, and the patient, to use the words of
Hildanus, “had her soul speedily sent to heaven.”
There is another disease, which is very apt to be confounded with
cancer, and which, at one period, resembles it very much. It begins
with a small tumor, like a phlegmon, of a dull colour, and without much
pain. This soon assumes a soft elastic feel, and bursts at the top; a
bloody matter oozes out, the lips of the orifice become tumid, and the
integuments ulcerate. The whole has a convex surface, the ulcerated
part being most prominent; and the sloping margins are red and painful:
The ulcer itself is foul, of a dark fungous appearance, and covered
with thick offensive matter, with sloughs in different parts; the
margins are hard, and lie, in a serrated manner, over part of the
sore: The pain is smarting. This sometimes spreads to a considerable
extent, and cuts off the patient. At other times, by the use of mild
dressings, good diet, and opium internally, the fungous surface sloughs
off by degrees, and shows a smooth red bottom, somewhat striated, and
of a glossy appearance, which contracts, and scabs over, like the
pseudo-cancer. The fungus, in this ulcer, never rises high; it is
generally slightly convex, being most prominent at the centre, and has
never the retorted trumpet-like appearance of some cancers.
Phagedena has sometimes, particularly on the yard, been confounded
with the cancerous sore. It has indeed the brown fiery colour, and
smarting pain, possessed by the cancerous ulcer; but it wants the
fungous appearance, which the cancer very soon assumes. It spreads
with greater rapidity, and is not surrounded by the same hardness. It
begins likewise more suddenly, and without any previous hard tumor. We
frequently hear of venereal buboes becoming cancerous; but this seldom,
if ever, happens; and phagedena has, in this case, been confounded with
cancer; for that spreading fiery honey-comb-like ulcer, which venereal
buboes sometimes turn into, is evidently of the phagedenic nature.
It was from allowing too great latitude to the description or
definition of cancer, as well as from the numerous divisions admitted
by the older writers, such as mild, raging, and the like, that many
diseases have come to be considered as cancerous, which are in their
nature perhaps radically different from it.
The mild cancer was said to begin slowly, with little pain, to continue
long indolent, and to ulcerate slowly: The ulcer was not very painful,
and frequently healed with a scab, or remained long stationary. This
evidently was not a cancerous disease, but the one which I have
described above. On cutting into this tumor, after extirpation, we find
it to be of a firm texture, the interstices filled with a kind oily
matter, and no cavities with thickened sides in its substance.
The malignant, or true cancer, begins with a hard schirrous tumor, with
frequent lancinating pain; the skin soon adheres to the gland, and
becomes slightly puckered, and of a livid or leaden colour; the veins
are more or less varicose, although the tumor be not large; and the
nipple, when the disease is in the breast, is generally drawn inward.
The integuments next become red, and a small opening forms, through
which is discharged a bloody serous-looking matter, generally in very
considerable quantities. The ulcer which succeeds this is, at first,
superficial, affecting only that part of the integuments which covered
the pointing of the glandular cyst or abscess. It is dark coloured
and fiery, like phagedena; but the edges are hard and ragged, and
overlap irregularly, in different spots, small parts of the surface
of the sore. In the course, however, of a few days, sometimes in a
few hours, a fungus protrudes, and increases more or less rapidly,
at the same time that the sore spreads laterally. This fungus is
very irregular, of a dark colour, and covered with sloughy-looking
pellicles. It generally sprouts out most toward the circumference,
so that the sore has often the appearance of the mouth of a trumpet;
or if the cavity in the middle be less, the fungus being less turned
out, it resembles a cauliflower. This fungus uniformly projects over
the margins, which are hard and red. The matter discharged is thin,
bloody, and exceedingly fœtid. On examining these glands, we find them,
in the commencement, to be hard, like a substance intermediate betwixt
gland and cartilage, and of an indistinct granulated structure. Soon
afterwards, we perceive small abscesses or cavities in different parts,
which are filled with a serous fluid, and the sides of which are hard
and firm, like gristle. These enlarge gradually, and new ones form; so
that were we to cut the gland, we should find it containing a great
number of these cavities[113]. Those which are nearest the surface of
the gland, generally enlarge most; and sometimes only one gains any
considerable size. Before this bursts, its sides become more opake, and
more blended with the rest of the gland, (which, where it surrounds
the abscess, becomes softer, rather more vascular, and more porous
or spongy than in other parts, and than it formerly was), unless it
distend beyond the substance of the gland, pushing the skin outward.
In this case, when it bursts, a great quantity of lymphatic matter
is discharged, and the part collapses, and then exhibits the usual
appearances of the cancerous ulceration: But, more frequently, we find
the abscess remain altogether in the gland, and only distend the skin
a little at the apex, where it points. When the abscess bursts, more
or less fluid is discharged, and immediately the inner surface begins,
like the orifice, to ulcerate. A fungus is produced from the sides of
the abscess, which fills up the cavity, and then protrudes from the
orifice. We, therefore, find, that when the cancerous abscess bursts,
the orifice at first assumes the appearance of a cancer which begins
in the cutis[114]; but very soon a fungus protrudes, and the ulcer
gradually becomes more convex, or more like a cauliflower.
[113] These are sometimes very irregular in their shape, and have their
sides very thin; so that, at first sight, they appear like cavities
formed by the separation of the fibres of the part.
[114] That is to say, the sore is rather flabby than fungous; for
cancerous ulcers which begin superficially, and without previous
abscess, remain a considerable time without forming fungus; but when an
abscess bursts, and the skin ulcerates in consequence, then the sore is
not superficial, but communicates with the abscess, which forms fungus
quickly.
These abscesses, with thick sides, are characteristic of cancer,
and are never found wanting in a cancerous gland. When they are not
present, we may be certain, that the tumor is a different kind of
schirrus. But although these be always found in the glands, and form
in them a certain mark of cancer, yet they are not necessary to the
existence of that disease; for the cancerous ulcer, like common ulcers,
may begin without previous abscess, as we observe in the cancer of the
skin, which, in nine cases out of ten, begins with excrescences like
warts.
By attending to these circumstances, we may generally form a pretty
just diagnosis. At the same time, it must be admitted, that,
occasionally, cases do occur, in which it is impossible to deliver a
decided opinion: Nor is it doubtful, that many ulcers are considered
as cancerous, which are of a different nature, and some of which admit
of a cure. In forming our judgment, we must be directed by the nature
of the first symptoms, and the history of the schirrous stage; by the
appearance and aspect of the fungus, and the other circumstances which
have been already described.
Concerning the peculiar state of the parts in cancer, or the proximate
cause, many opinions have prevailed; but these, however they might
differ in certain points, have almost unanimously agreed in admitting
obstruction as the chief cause of this disease.
Until lately, the melancholic humour was supposed to be the fluid which
was obstructed, and accumulated, in consequence of which it fermented,
and produced a burning ulcer; and whatever promoted the generation
of this humour, was currently admitted as a remote cause of cancer.
Women, says Ambrose Paré, are more subject to schirrus than men;
“because their liver is warmer, and their spleen being weaker, is less
able to purge the blood of choler.” Grief and chagrin, by promoting
the formation of this fiery fluid, were accordingly considered by the
celebrated Heister, as very apt to induce the “cancerous diathesis;”
and he slyly adds, by way of corollary, that “old maids, and women who
do not breed, are very subject to cancer in the breast[115].”
[115] Heister’s Institut. Vol. I. p. 229.
Concerning the particular changes which took place in the nature of
this obstructed humour, many different opinions prevailed. Some thought
it necessary, that the black bile should be charged with an acid,
and that this produced ulceration, when “its sharp cutting points
had surmounted and destroyed the volatile smegmatic and balsamic
salts of the blood.” Others conjectured, that by an “adustion or
over-concoction,” it grew sharp and burning: But Wiseman observes,
that it is more probable that it becomes somewhat arsenical. It
would, however, be useless to enumerate the different changes which
this imaginary humour was supposed to undergo. It is sufficient to
observe, that these were almost universally believed to depend upon the
previous stagnation, in consequence of obstruction; and this leading
point has uniformly been insisted on by every succeeding author,
whatever might have been his particular notion with regard to the
nature of the obstructed fluid, whether bile, blood, or lymph; and
even the anatomical structure of the part has been brought in support
of the doctrine of obstruction. One of the latest writers[116], though
he talks nothing of “coagulating acids[117],” yet insists fully on
this mechanical cause as the origin of cancer; “for,” says he, “the
circulation in the glands being carried on by a set of vessels much
more minute than those with which other parts of the body are supplied,
(let this be proved), obstruction will much more readily and easily
occur in them than in other parts.”--“When the substance of a gland
happens to be the part, a determination is made to this, being neither,
as is found by experience, so proper as the cellular substance, or
the formation of pus, nor, from its softness[118], so susceptible
of inflammation, as a membrane; an indolent hard swelling, called a
schirrus, comes, merely by the _obstruction_ and _distension_[119] of
its different vessels, very naturally to be produced.”
[116] Bell on Ulcers, p. 319.
[117] Dioni’s Chir. p. 248.
[118] Does inflammation depend upon the hardness or softness of the
inflamed part?
[119] One should expect, that the distension of the vessels would
diminish the cause of obstruction, or remove it altogether.
It is rather unlucky, that the advocates for obstruction have made it
the cause of simple inflammation, scrophula, cancer, &c.; and therefore
all these diseases ought to be nearly, if not entirely, similar in
their nature, and to require exactly the same means of cure.
Some surgeons, perhaps from a desire of singularity, or from a defect
of their organs of sight, declared, that they had detected little
worms in the parts, which, eating it up, produced all the disagreeable
symptoms of cancer; and that to their introduction the disease was
owing. The cure which they confidently proposed, was applying a piece
of cold veal to the part, which would tempt the animals to quit their
devastation. Others, perhaps originally from ridicule, though latterly
in sober earnest, told their readers, that there were no worms, but a
little wolf in the part, which might be made occasionally to show its
head, by holding a piece of meat before the ulcer.
Strange as this doctrine of living creatures producing cancer may
appear, it is nevertheless adopted by a late very ingenious writer.
When hydatids find their way into “a solid substance,” the consequence,
in his opinion, will be cancer; and the success of an operation will,
he conjectures, depend, in a great measure, upon these animals being
confined in a common cyst, for then they may be all removed; whereas,
if they be unconnected, some of the smaller ones may be allowed to
remain[120]. From the surface of the cyst, which contains the animal, a
fungus shoots out, and thus acts as a barrier between it and the skin;
or, if the animal have been in the stomach, it separates it from the
coats of that viscus, “preventing suppuration in the one instance, and
absorption in the other[121].” This suppuration, “and disposition to
fungate before the skin is broken,” if I understand him, is produced
by the death of the animal; for, says he, “if hydatids possess the
principle vitality during their transparent state, and their opacity is
the effect of the loss of that principle, would they not, in the latter
stage, stimulate the part in which they are situated to suppuration, as
we find the case with the Guinea worm when dead[122]?” Concerning the
manner in which these animals produce the symptoms of cancer, we are
told, that “this enlargement of a foreign body, in a solid substance,
and so extremely sensible as the breast, cannot but be attended with
intense pain, and frequent inflammation[123].” A doctrine not far
removed from that taught in the humoural schools, which maintained,
that the coagulation and inspissation of the fluids distended the
follicles of the glands, producing many cavities, and much pain[124].
[120] Adam’s Observations on Morbid Persons, p. 184.
[121] Idem, p. 185.
[122] Adam’s Observations on Morbid Persons, p. 184.
[123] Idem, p. 161.
[124] Van Swieten’s Commentaries, article Cancer.
That hydatids _may_ be formed on a cancerous gland, I shall not
dispute; but that they are generally to be met with, or are in any
respect essential to the disease, I cannot admit. In all the cancerous
breasts, testicles, and tumors, which I have examined, I never saw any
thing which could be considered distinctly as a hydatid; so that I
suspect, that under this name have been described the small cancerous
abscesses, with thick cartilaginous sides, which we so universally meet
with in schirro-cancerous glands. We likewise find cancer take place
in circumstances in which no hydatids can be found. Thus, for instance,
a cancerous wart being knocked off the face, a cancerous ulcer is
produced; but no hydatid is to be found at the base of the wart to
produce this.
When cancer has continued some time, it was believed that the matter
was absorbed, taken into the blood, and that all the humours were
speedily assimilated; and it was by this absorption and assimilation
that they explained the fatal and rapid progress of relapses, after
an apparent cure had been obtained. That matter is absorbed, is an
undeniable fact; but the only effect which is produced by this, is on
the lymphatic glands[125], which intervene betwixt the sore and the
heart; for, beyond these, the matter does not pass qua virus, but is
changed in its nature and properties, as is the case with every other
part or production of the animal, which is absorbed and formed into
part of the blood. Neither cancerous matter, nor variolous matter, nor
syphilitic matter, ever are formed in the blood, or ever can enter into
it, unless by means of an wounded vessel. This point I shall consider
more fully, when I come to treat of the venereal inflammation. Here I
shall only observe, that were the reverse true, then the contagious
matter must pass through every gland, and every portion of the
human form, in as much as the blood circulates in every point; and,
therefore, every spot should become diseased, and every part, in the
same circumstances, should become diseased at the same moment[126].
Disease is not spread in the living system mechanically, by the
absorption of matter, which is conveyed over the whole body, but by the
sympathetic connection of parts, which has been already explained, and
which will afterwards be farther illustrated. It is in consequence
of this, that a distant part shall become diseased, and yet all the
rest remain healthy; and even where every part becomes affected, and
a general disease is suddenly produced from a local sore, as, for
instance, in small-pox, there is no diffusion of matter, nor is it ever
conveyed beyond the lymphatic glands.
[125] Mr. Hunter supposes, that the mere absorption of schirrous
substance before matter be formed, will affect the glands; but it is
difficult to ascertain the certainty of this, as small abscesses are
formed very early. I have formerly mentioned, that every part of the
animal is changed in its nature, at the moment of being absorbed: If
so, schirrous substances lose all specific property, and cannot affect
the glands. Pus, again, being a foreign matter, is absorbed unchanged,
and continues so until it reaches the glands.
[126] It may be said, that different parts have different
susceptibilities of assuming the morbid condition; that the bones are
longer of becoming affected than the soft parts, &c. Admit this, and
still it must be explained, why every part of a similar structure, &c.
should not be affected at the same moment. All the glands should become
diseased at once; all the bones should inflame at the same time; and,
instead of finding one or two organs affected, in consequence of the
previous existence of a local disease, we should find the whole system
rapidly becoming diseased.
In this particular complaint, the consequence of sympathetic action,
or the propagation of action, is sometimes the induction of the
same disease in other parts; but most commonly the effect is the
establishment of the hectic, or diseased formative action; for an
explanation of which I refer to the dissertation on simple inflammation.
By examination, we find, that, in many instances, cancer is evidently
produced by the same causes which are capable of producing simple
inflammation; and, in every instance, I apprehend, that although the
causes may be obscure, yet they are exactly of the same nature. It
is, however, a general opinion, that this disease arises frequently
from some unknown and mysterious cause which we cannot detect, and
which, therefore, has been resolved into some constitutional taint,
or cancerous ferment. But, so far as we know, the constitution is
perfectly healthy in the commencement of this disease; nor is there
the smallest of that it resembles scrophula, in depending upon any
peculiarity of constitution, before the causes operate.
Blows, bruises, and other exciting causes of inflammation, are apt
to produce cancer; but, in many instances, we can detect no evident
local cause acting directly on the part. In the breast, for instance,
we frequently perceive cancer commence without the interference of
any topical agent. In these cases, however, we may uniformly detect
an irregularity or disappearance of the menstrual secretion. It was
formerly observed, that the uterus and mammæ exhibited very powerfully
the sympathy of equilibrium; and it is upon this doctrine, which it is
unnecessary farther to illustrate, that we are to explain the affection
of the breast, which so frequently takes place in consequence of the
cessation of the menses; for when the active state of the uterus is
lost, the action of the mammæ is preternaturally increased, and a
species of slow inflammation is induced. It is upon this principle only
that we can explain why cancers are so frequent at the cessation of
the menses[127]. It is ridiculous to suppose that this discharge acts
as a drain to the constitution, and carries off impurities, which would
otherwise collect elsewhere, and produce local diseases. The breast is
almost the only organ which becomes thus affected without any agent
acting directly upon the part alone; for, in most other instances, we
may detect the operation of such causes at least as tend to induce
simple affections of the same part; but, in both instances, the modus
operandi of the cause is alike, only circumstances are somewhat varied.
[127] It was supposed, that when the menses were obstructed, the
impurities were sent by communicating vessels to the breast, where they
lodged, and produced cancer. Vide Vesalii Opera, p. 1092. Fabricius de
Tum. p. 118.
Le Dran observes, that when schirrus, from any cause, takes place in
the breast, before the cessation of the menses, it uniformly becomes
more painful when any irregularity of that discharge occurs. Vide
Memoires de l’Acad. de Chirurg. Tom. III. p. 22.
When the inflammatory action is slowly induced, whether by a bruise,
or any other cause, acting directly on the part, or by sympathetic
union with another part, we find, that the tumor which is consequent
to this, seldom manifests a disposition to remove quickly, or assume
the healing process. The part neither performs any distinct and acute
inflammatory action, nor does it resume its natural condition and
appearance, but remains in a new state, different from either, which I
will call the state of simple schirrus[128]. If this state, which may
follow the application of the common exciting causes of inflammation
in any part, take place in cellular substance, or similar parts,
which are possessed of no glandular structure, then a chronic tumor is
produced, which is either slowly diminished by absorption, or at last
unable to carry on its actions in perfection, being, in some respect,
insulated, and deprived of the support of the surrounding parts[129];
a diseased action, or morbid performance of its actions, takes place;
a slow inflammatory condition is produced[130], and at last ulceration
succeeds. This, in general, forms pseudo-cancer, provided that the
constitution be simple, that is to say, healthy: But if it take place
in a scrophulous habit, the tumor is apt to become scrophulous, having
its morbid actions modified by the morbid condition of the system. If
this event take place in a lymphatic gland, instead of the cellular
substance, then the tumor is still more apt to become affected with
scrophulous inflammation, in consequence of even a very trifling
scrophulous modification of the habit. If this state be produced in
a secretory gland, the affection is somewhat different from that in
simple parts, or those which do not secrete; because the inflammatory
action becomes somewhat modified by the natural secreting action of
the part; and, in this point of view, the gland may be considered as
possessing a specific constitution, although the general constitution
be simple; for, naturally possessing a peculiar mode of action, it
follows, that new actions induced in such a part, ought to be performed
in a different manner from the same actions in parts which naturally
do not possess this peculiarity, and that the actions ought to be
specifically different. When these parts are attacked with acute simple
inflammation, it differs from inflammation in the cellular substance in
certain circumstances, and particularly in being much more tedious; but
when the nature of the part is still farther altered by the accession
of a slow inflammatory action, which operates in the manner above
described, then it assumes a specific inflammation, which ends in
ulceration. The exact, or specific nature, of this, is various; and the
state, which we call cancerous, is probably only one of the varieties
of this morbid inflammatory action; and whether the part shall assume
this variety, or some other variation, as, for instance, pseudo-cancer,
depends probably upon local circumstances, which we cannot as yet
detect or explain. If, however, the constitution possess any specific
mode of action, the tumor generally assumes nearly the same mode;
and, therefore, in scrophulous people, these tumors more frequently
become affected with scrophulous inflammation, than with cancer: At the
same time, if the previous change on the gland, induced by the slow
inflammatory condition, have been great, the scrophulous condition,
which it possesses in common with the rest of the system, becomes
modified in it, in the same way as the simple condition, in healthy
habits, is modified by the new or schirrous state of the gland; and,
therefore, the scrophulous inflammation is sometimes different, and the
ulceration more fungous than in other parts.
[128] Warts are, with regard to their power of acting, to be considered
in the same light with simple schirri.
[129] See the Note to p. 354.
[130] The simple schirrus now assumes that specific mode of
inflammatory action which it is to continue, and may now be called the
scrophulous or cancerous inflamed schirrus.
The causes, then, of simple inflammation, when they operate slowly,
or leave the part in a state neither inflamed nor healthy, give rise
to a chronic enlargement, and change of nature, which I have called
simple schirrus[131]. This performs, like every other part, certain
actions, which are intended for its own support, and which must make
a part of the general action of the system, or be in unison with the
rest of the body. But as its actions are different in nature from
those which any part of the body naturally ought to perform, and as
originally this organ, (which, from the changes induced on it, is to be
considered as new and extraneous), formed no part of the human frame,
there is not that connection betwixt it and the rest of the system,
which is necessary for its support. It, therefore, does not derive the
same aid and support from the neighbouring parts which natural organs
do, (for no part, or individual organ, can exist and support itself
singly, and independent of the rest), and, accordingly, must soon come
to suffer. It is unable to perform its necessary actions in perfection;
they become morbid, and of an inflammatory nature. The tumor is now an
inflamed schirrus; and this inflammation either assumes a modification,
from the specific nature of the constitution, or from the peculiar
nature of the tumor itself, which, as has been explained, is different
from the healthy state of the tumid part. We have, therefore, the
scrophulous, the cancerous, the pseudo-cancerous inflamed schirrus; and
the symptoms of these different kinds of schirri, and the appearance of
the ulceration, will, cæteris paribus, be modified by the nature of the
part affected. The same disease, therefore, exhibits slight variations
in different organs, as has been described in the history of cancer,
and might, therefore, were we inclined to multiply distinctions, be
considered as so many different diseases.
[131] Schirrus has generally been enumerated as one of the terminations
of inflammation; but it cannot, properly speaking, be considered as
such. There are only two kinds of termination, one in death, as, for
instance, gangrene; the other in recovery, which is accomplished either
directly by resolution, or indirectly by suppuration. Schirrus is not
produced by a perfect and complete cessation of inflammation, but by a
continuance of a low degree of inflammation, which renders the state
of tumefaction which attends it natural to the part, before it goes
off. This state, then, is not a termination of inflammation, but a
consequence of its continuance.
This disease is most apt to take place in elderly people, (in so much
that some consider it as peculiar to old age); because in them, parts
sustain injury of their actions worst, or are less able to recover
from them. Hence, two consequences follow: First, Simple schirrus is
more easily produced, resolution of inflammation being more difficult,
especially in parts which are, at all times, rather tedious in their
recovery, when inflamed: Second, The simple schirrus is more apt to
inflame, or have, what may be called, _its_ necessary actions impeded
and deranged. It must, however, be remembered, that there is no age
whatever exempted from this disease: I have seen it distinctly marked,
and attended with a fatal event, in children of five years old[132].
[132] I have known two cases of this kind; in both the eye was
affected. One boy had his eye extirpated; but a small part being left
by the surgeon at the angle, the disease returned, and proved fatal.
In another, the disease was in its incipient stage; but the relations
would not submit to an operation.
It is a controverted point, how far it is possible to produce cancer
by inoculation; some maintaining, that the application of cancerous
matter to a sound part will induce the disease; others, that it is
altogether harmless. Analogical evidence is certainly in favour of
the first opinion; because the majority of specific ulcers may be
inoculated, and have been so by accident. But, at the same time, it
must be admitted, that there are few well established cases of this
particular point. We find, however, that, like the venereal matter, the
cancerous, when absorbed, induces a disease in the lymphatic glands, of
a cancerous nature. We would, therefore, be led to conclude, that if
the matter be capable of inducing cancer by absorption, in a distant
part, it ought likewise to be capable of producing the same disease
in another person by inoculation. The same be said of the spongoid
inflammation, &c.
From these observations, it will, I presume, appear, first, That
when a part is incapable of performing the actions necessary for its
preservation in a state of health, it generally slowly assumes the
inflammatory state, which goes on to ulceration; but the part being
unable to support its natural action, can much less perform the actions
necessary for restoration from this morbid condition, which, therefore,
continues permanently and progressively increasing; that the nature of
this unhealthy action is not always the same, but admits of variations
dependent upon certain conditions in the previous state of the part
affected, with regard to which we are greatly in the dark. Cancer,
pseudo-cancer, spongoid inflammation, &c. are some of these variations.
Secondly, Cancer, and all these variations, are originally, in the
strictest sense of the word, local diseases, depending neither upon
any constitutional affection, nor the presence of any general cause.
They do, however, in progress of time, affect not only parts in their
vicinity, but also the system in general, producing, by means of
sympathetic actions, specific hectic affections, as has been formerly
explained, when treating of simple hectic. They likewise spread over
more surface in the part at first affected, and produce the same morbid
actions without variation, by means of the sympathia consociationis
serpens. They also induce a similar disease in the nearest lymphatic
glands, by absorption.
_Of the Prevention and Treatment of Cancer._
From what has been said, it will appear, that cancer is to be prevented
by using the most vigorous means for the removal of simple schirri,
upon their first appearance. Of these, local bleeding is the most
powerful, and ought to be freely employed. Next to this, an issue in
the neighbourhood of the part ought to be most depended on; and these
two remedies must be employed early, and continued carefully. Whenever
a simple schirrus arises, we ought to be on our guard, in whatever
situation it may be placed; but, if it occupy a secretory gland, we
require to be doubly vigilant. This, at first, is not painful, at least
the patient only complains of slight uneasiness shooting for a moment
through it. This circumstance too frequently prevents the patient from
attending to it; for where there is no inconvenience sustained, there
is little inducement to apply for assistance; and, not unfrequently,
an ill-judged modesty contributes to this delay. But, although the
patient may be little concerned at this period, yet the surgeon must
not observe the same indolence. Aware of the dangerous consequences of
allowing the tumor to follow its natural course, he will apply leeches
once and again, and insert an issue as near the part as possible. The
remedies called discutient have been much recommended at this stage;
such as sal ammoniac dissolved in vinegar; and this is sometimes
useful, but perhaps not more so than the vegetable acid by itself:
When it does not interfere with bleeding, it may be usefully employed.
By means of these remedies, we may frequently remove recent tumors,
which depend merely upon the enlargement of an organ, without any other
considerable change of structure. But it is more difficult to remove
tumors which are not produced by the mere enlargement of a part, but
depend upon a change of structure, or the formation of new parts; as,
for instance, warts, polypi, &c. The small indolent tumors, however,
which take place in the cellular substance, may sometimes be removed by
the early use of these remedies.
When these means have either been neglected, or fail when employed, and
the schirrus begins to inflame, there is little hope of performing a
cure by either local or general applications; and extirpation affords
the only chance of recovery which can be depended on. But, as it is
not always at the very first certain that the schirrus has assumed the
cancerous inflammation, and is not curable, the operation ought not to
be advised in the first instance, or upon the very first appearance
of the pain, or symptoms of commencing inflammation; on the contrary,
we ought to have recourse to local bleeding, the use of issues, mild
diet, and perhaps the use of cicuta; but if these remedies do not
evidently arrest the progress of the disease, diminish the pain very
considerably, and make the tumor perceptibly softer and less, in the
course of a few weeks, we ought, without hesitation, to advise the
removal of the part, which I shall presently consider.
The local bleeding is to be performed with leeches, which are
preferable to the scarificator, being attended with less irritation.
Three leeches may be applied to the part every second day, as has
been proposed by some writers on this disease. This practice must
be continued for a considerable time; and, during the intervals of
bleeding, cloths dipped in cold water ought to be applied. If, in the
course of a month, the tumor becomes freer from pain, and softer, we
may apply the leeches only every third day, and continue this for
another month, and afterwards either persist for some time longer in
the same way, or repeat the application at longer intervals, according
to circumstances. But if, on the contrary, the tumor become rather
larger, and more painful, as sometimes happens, when the disease is
farther advanced before we begin, and if the constitution suffer by the
repeated evacuations, we must desist.
Issues may be formed, either by introducing a small seton superficially
on each side of the tumor, or by blistering the part, and afterwards
keeping it open with savine ointment. The latter of these methods
is not admissible, when the disease has proceeded so far as to make
the skin adhere to the gland, and become puckered; indeed, at this
period, issues formed in any way ought never to be advised, unless
the operation will not be consented to; because the chance of their
producing a cure is very little, and we lose time by trusting to them.
Mild and spare diet has a very considerable influence over this
disease, in almost every period, and contributes greatly to retard its
progress. It ought therefore rigidly to be conjoined with the bleeding
and issues, in the commencement of the disease, and will tend to abate
the action in the part, and promote its resolution. The diet ought to
consist of stewed apples, or prunes, panada, and weak broths, with
bread. It has even been proposed to prohibit almost entirely the use of
solid food, and to allow the patient nothing but water for the course
of several weeks. This was much recommended by M. Pouteau, who was led
to make trial of it by the success attending the empirical practice
of an ecclesiastic. It was afterwards enforced by Callison; and more
lately abstinence has been favourably mentioned by Mr. Pearson, who
relates some cases of cancer, or appearance of cancer, in the uterus,
in which it produced very astonishing effects, abating the pain,
diminishing the swelling, and re-establishing the general health.
By means of these remedies, we may sometimes succeed in removing by
degrees a schirrus, after it has evidently begun to inflame, and
threatens to become cancerous. But if, notwithstanding these remedies,
the disease evidently continues to increase, or if, in the course of
a few weeks, they do not produce an evident effect, we cannot with
propriety delay the operation, which is the most certain method of
cure, and one which succeeds in a majority of instances, if early and
properly performed; nor ought any other method of treatment to be
proposed in opposition to it, unless in the very commencement of the
inflammatory state; and it is in this period only that I propose the
above treatment, unless the patient absolutely decline the operation;
for when the skin becomes puckered, and the inflammation has continued
clearly for a considerable time, without any measures being taken to
remove it, the success of any local or general remedy is exceedingly
precarious, and delay is not only useless, but frequently dangerous. It
has, however, been doubted by some very ingenious surgeons, whether it
was proper to advise the operation at any period, they believing, from
the number of relapses, that it was almost useless; whilst others have
been against the early performance of it, on the principle, that some
parts already diseased might not have, at this period, become evidently
affected; and, therefore, might inadvertently be allowed to remain.
The late Dr. Monro[133], from observing, that almost all the patients
on whom, to his knowledge, the operation had been performed,
relapsed, is inclined rather to adopt the palliative treatment, than
the extirpation. He takes for granted, that, in the generality of
cases, cancer depends upon some internal cause. In these cases, he
is decidedly averse from the operation, and advises it only when the
disease occurs owing to blows or hurts in young and healthy people.
But, in considering this opinion, we are to remember, that a great
many of these cases may be supposed to have been very far advanced
before any operation was performed; and likewise, that the method
of operating, in that period, was extremely unfavourable to a cure,
the wound being kept open, and suppurations and ulceration rather
encouraged than avoided. More lately, Mr. Hill of Dumfries has
published an account of cases, where the operation was performed in
more favourable circumstances, and of these not a seventh part suffered
a relapse. The present Dr. Monro gives even a more favourable account;
for, if I am not much mistaken, he observes, in his lectures, that not
one-third of the cases in which he had been consulted, had relapsed.
From my own observations, I cannot judge very accurately; because many
of those on whom I have operated, came from parts at a great distance,
and with which I had no intercourse; consequently, I could not hear of
the result of those cases: But of the cases, the sequel of which I have
heard, not a fifth part have relapsed; and in those the operation was
performed at a period when the axillary glands had become diseased, but
were not evidently so; and, therefore, were not extirpated; for, in all
of them, the disease reappeared in the lymphatic glands. But, even from
this relapse, the patients may be cured by a second operation. We may,
therefore, conclude, that, if the operation be early performed, the
majority will recover; and even although the disease should afterwards
appear in the lymphatic glands, the patient is not incurable; for we
frequently succeed in extirpating cancers, when the glands are very
much affected before we are applied to. I have operated in cases where
I was obliged to dissect the glands, from the axillary artery alongst
almost all its course in the armpit, and which reached well nigh to the
articulation.
[133] Med. Essays, Vol. V. p. 422.
With regard to the argument against the early extirpation, founded upon
the possibility of the disease having affected parts in the vicinity,
which have not yet evidently become diseased[134], I may observe, that,
upon the same principle, we ought not to operate until the axillary
glands swell; because they may be affected, although they be not yet
evidently enlarged; and, therefore, may give rise to a relapse. If we
only remove the single gland in the breast, which is hard, we doubtless
run a great hazard of a relapse; but, I apprehend, that this ought
never to be done, and that the whole of the glandular part of the
breast ought to be removed at once; because we thus more certainly
prevent a return of the disease, which we cannot otherwise, with any
certainty, do. The additional pain is very inconsiderable; and we can
derive very little advantage or benefit from leaving a part of the
mamma behind.
[134] Pract. Obs. on Cancerous Complaints, by Mr. Pearson, p. 50.
The caustic has been proposed, instead of the knife, for the removal of
cancer schirrus; but it is much less certain, more tedious, and even
more painful. Instead, therefore, of recommending itself to timorous
patients, this practice is still more to be dreaded than the excision,
which is more terrible in anticipation, than in the actual performance
of it.
The caustic most commonly, and indeed almost universally, employed,
is arsenic, mixed with various inert substances, and formed into a
paste or ointment[135]. This has been applied in two ways; first,
directly upon the skin, covering the schirrus, and then, after this
is destroyed, upon the schirrus itself, destroying it layer by layer;
second, directly upon the skin, and then, instead of applying it to the
gland, to put it round it on the surrounding cellular substance, and
by gradually destroying this round the gland, to turn out the schirrus
entire. This was the practice of Mr. Guy, who gained considerable
credit by his success; and, since his time, it has occasionally been
performed with success by some others[136].
[135] Arsenic mixed with sulphur, and powdered crow-foot, and made into
a paste with yolk of egg, forms Plunket’s composition. Mixed with forty
times its weight of powder of belladona, it forms an application which
some time ago was much in repute in North America.
[136] Justamond on Cancers, p. 141. This gentleman relates a case, in
which, by destroying the skin with lunar caustic, and then applying
arsenic, he removed the gland. The arsenic, in this instance, was fused
with antimony, in proportion of two parts of the first to one of the
last. This was powdered and mixed with equal parts of powdered opium,
and made into a liniment with yolk of egg.
This method, however, is liable to several material objections: It is
uncertain in its issue; for, if the gland be not completely removed,
the disease makes a rapid progress afterwards. It frequently happens,
that some smaller glands around the large one are affected; and
these are greatly irritated by the action of the caustic in their
vicinity: It is more painful than the operation with the knife; and the
subsequent process of healing, even granting the method to succeed in
removing the diseased part, is much more tedious than when the incision
is employed, and union by the first intention procured.
On all these accounts, but most especially on account of its
uncertainty, the method of cure by caustic can never be sanctioned by
any modern surgeon, much less can it ever be held up in opposition to
extirpation by the knife.
This practice, which has had many advocates for its employment in
schirrus, has been equally recommended in cases of cancerous ulcers;
but here it is still less admissible; for the extent of diseased parts
is generally greater; the neighbouring parts are affected to a greater
distance; indurated and diseased lymphatics frequently extend from the
breast to glands in the axilla. It is, therefore, next to impossible
to turn out the morbid parts, as “nuclei,” by destroying the substance
around them; and it is equally improbable that we shall, unless the
sore be very small, and the caustic very strong, be able to make it
slough off in successive layers. Farther we can propose no advantage to
ourselves, from employing caustic in preference to the scalpel; because
in every instance in which we can destroy the parts by means of this,
we can equally safely, infinitely more speedily, and with much less
pain, remove the parts with the knife. There is only one case in which
caustic is useful, and that is merely as an appendage to the operation
of excision. When we dissect off ulcers from parts where, owing to
the want of cellular substance, the skin is not lax enough to be
brought over the parts, or when so much of this has been removed, that,
although lax, it cannot be made to cover it, we may find it of service
to rub the bottom of the wound with lunar caustic, as we thus stop the
oozing of blood, and destroy any little portions of the diseased part
which we may have left.
For the purpose of destroying cancerous ulcers, many caustics and
escharotics have been proposed, such as the arsenic, corrosive
sublimate, lunar caustic, &c. Of these no one seems to possess a
preference over the rest, if we consider only their local action; but
some of them, especially arsenic, are apt to produce bad effects, and
that very unexpectedly, on the constitution.
After making these remarks upon the method of cure, I shall conclude
with some observations on different remedies, which have been proposed
as palliatives, where the operation is not admirable, or will not be
consented to, and which have even been supposed capable of changing the
mode of acting altogether, and producing of themselves a cure. These
remedies I shall divide into general and topical.
Of the general remedies, those which have been most frequently, and
with the greatest confidence, employed, are narcotics, such as the
cicuta, opium, nightshade, &c.
The cicuta is a medicine which was, at one time, in very high repute,
and owed its reputation to the experimenting talent of Storck, who
has written several libelli on this plant. According to him, cicuta
possesses very evident powers over cancer, and has cured a great many
cases; but, in less prejudised hands, it has been much less successful;
and even in many of the instances adduced by Baron Storck of its
utility, it is by no means proved, that the disease was really cancer.
The present opinion of the public seems to be very unfavourable with
regard to this medicine; and from the numerous instances in which it
has failed, this opinion seems to be very just. Alongst with the proper
local applications which have been formerly noticed, it sometimes is of
service in removing simple schirri[137]; but I have never found it of
any service when the schirrus had affirmed the cancerous inflammation,
much less when it has proceeded the length of ulceration. In the last
case, I have never found it even produce the temporary melioration
which many talk of.
[137] If I am not mistaken, the present Dr. Monro mentions, in his
lectures, one instance, in which a small schirrus appeared to be
removed by it; but whether this was simple or cancerous, I do not know.
The common way of exhibiting the hemlock, is to begin with small
doses, and increase these gradually, until they produce vertigo: For
this purpose, we may begin with two grains of the extract, or four of
the powder, recently prepared, twice or thrice a-day, and gradually
increase the quantity[138]. In this way, we find that some patients
have come to take an ounce of the extract daily; but if a much less
quantity than this produce no good effect, we may consider it as
useless to continue a remedy, which, in this dose, must injure the
constitution every day that it is continued. On the continent, the
hemlock has been used in the form of a bath; but it is so disagreeable,
that few can be brought to use it.
[138] As different parcels of this medicine may not be of the same
strength, it is prudent, when we begin a new supply, that we diminish
the dose at first, if it have formerly been very considerable. By not
attending to this, fatal effects have followed.
The belladona has been much recommended by Lambergen, who tried it in
many cases of cancer; but these trials, when repeated with attention,
have not been greatly in favour of the remedy. During its use, he kept
the bowels open with clysters, administered every second day. The
dose, at first, ought to be a grain of the dried leaves, made into a
pill. This, in the beginning, is to be given morning and evening, and
afterwards more frequently.
The hyocyamus has also been frequently used in cancer, and was very
much in repute with the ancients. I have tried it occasionally, but
with very little effect. The dose with which we begin, is two grains of
the extract.
The aconitum is a more powerful and dangerous narcotic, in so much that
a quarter of a grain of the extract is generally the dose with which we
begin.
The solanum dulcamara, Paris quadrifolia, phytolacca, &c. have been
likewise recommended and employed, but are now so little used, that it
is unnecessary to take any notice of them here[139].
[139] I have tried the hepatized ammonia, but without any benefit.
The laurus cerasus is a very powerful narcotic, and has been used, in
this particular complaint, by Richter, but with very little success.
The most common preparation of this medicine, is the distilled water;
but the dose of this is very uncertain. Some have, therefore, proposed
to give, for a dose, four or five grains of the fresh leaves infused in
a little water.
The digitalis has a considerable power of abating vascular action, and
may, therefore, be of use, in the same point of view with abstinence,
bleeding, &c. in abating the action of schirri; but concerning its
real utility in this disease, I cannot say any thing with certainty.
Opium is seldom employed with an intention of curing this disease,
although it is probable, that it possesses just as much power over
cancer, as those other narcotics which have been more frequently used.
It is, however, liberally employed with a view to abating the pain of
cancerous ulcers.
Tonic remedies have frequently been used in this disease; but although
they may sometimes improve the general health, yet they never produce
any effect upon the local disease. On this account, they are now very
seldom employed.
Arsenic is a medicine, which has, by some, been considered as a
specific against cancer[140]; but even those who maintain this, add,
that although they _believe_ and _think_ so, yet they have not been
able to administer it in such quantities as to produce any good effect.
[140] Justamond on Cancers.
Mercury[141] has also been recommended; but there is no fact more
certainly ascertained than this, that mercury uniformly exasperates
this disease, especially when it has proceeded the length of
ulceration. In this case, the sores enlarge rapidly, become much more
painful, and bleed frequently. It is worthy of observation, that those
who are affected with cancer, have in general the mercurial action
induced very easily and very speedily[142]; and the changes which take
place on the ulcer are equally rapid. This circumstance, of mercury
increasing the disease, in so marked a manner as it usually does, ought
not only to make surgeons careful of exhibiting this remedy, upon
slight suspicions of the sore being venereal[143], but may likewise
be attended to as a step toward the discovery of a better mode of
treatment for cancer than we yet possess; because if, at any time,
we discover the means of directly displacing and counteracting the
mercurial action, we may perhaps find the same to be useful in abating
the cancerous; these two actions appearing to possess some general
coincidence, from their mutual effect in increasing each other.
[141] Alongst with this, it was customary to prescribe decoctions of
guaiac, sarsaparilla, &c.
[142] It likewise continues very long after giving up the use of the
mercury.
[143] Some cases of this kind I have already mentioned.
Copper, in the form of cuprum vitriolatum, has been used in cancer; and
one case is recorded, in which it is said to have produced a cure; but
in every other case it has failed; and, from the violent effects which
it is apt to produce, considerable danger attends its exhibition.
Muriated barytes has been proposed as a cure for this disease; but now
none employ it with this expectation.
The same remedies which internally have been supposed to cure cancer,
have also been proposed as local applications.
Amongst the older practitioners, narcotics were very currently employed
as a dressing for cancerous sores. Vesalius used cloths dipped in
the juice of the solanum; whilst others employed it mixed with oil
of roses, and preparations of lead and antimony. Others had recourse
to the hyocyamus; whilst of late the cicuta poultices seem to have
superseded the use of most other narcotic preparations. These have,
undoubtedly, in many cases, abated the pain, and diminished the fœtor;
but this is all which can reasonably be expected from them; and even
this expectation will not always be realised.
Carrot poultices are still more useful, as they possess the property
of abating the fœtor, in a degree superior to the hemlock, and give
generally as much ease. This fœtor has been long compared to the smell
of hepar sulphuris, and lately has been supposed to arise altogether
from the formation of a substance of this nature, consisting of sulphur
and volatile alkali. As it has been too much the case in medicine, to
overlook causes, and attend to effects, so we are not to be surprised,
if we find some physicians proposing to cure cancer, by remedies
which shall decompose the matter which is yielded in that disease, or
destroy the effect of the morbid action, whilst the action itself is
overlooked[144]. From experiments made upon the hepatized ammonia, it
was found, that the oxygenated muriatic acid was the best agent for
decomposing it, and destroying its smell. This fluid was, therefore,
highly recommended as an application for cancerous sores; and, in many
instances, it will indeed be found to correct the fœtor, which is
certainly one advantage; but it never will perform a cure.
[144] Although the fœtor may depend upon the presence of hepatized
ammonia, yet this does no harm to the ulcer. On the contrary, I have
sometimes found the application of this fluid, when mixed with water,
have the effect of abating the pain.
Carbonic acid has been said not only to correct the fœtor, but also,
in some instances, completely to cure the disease. It was long ago
proposed by M. Peyrilhe, and of late it has again been brought
forward by Dr. Ewart, who has published a case in which it produced
cicatrization; but although, upon his recommendation, it has been
frequently employed, yet it has very seldom been of any considerable
service, and I have heard of no instance in which it produced any
permanent amendment. It would rather appear, that the opinion of M. de
Fourcroy was the just one: “After the first applications (says he),
the cancerous sore appears to assume a more favourable aspect, the
sanies which flowed from it becomes whiter, thicker, and purer, and the
flesh has a redder and fresher colour; but these flattering appearances
are deceitful, nor do they continue long, for the sore speedily
returns to its former state, and its progress goes on as before the
application.” The best method of applying this, is by means of a
bladder, the mouth of which is fastened round the sore, by means of
adhesive plaster. The air is introduced by a pipe inserted at the other
end. When first applied, the gas produces a sensation of coldness,
which is soon followed by a glowing heat, and abatement of the peculiar
pain of the sore. At other times, it, from the first, produces a
smarting, and makes the patient rather more uneasy. This is especially
the case if we use the fermenting poultice, instead of the air already
extricated.
Digitalis, applied either in poultices or infusion, has been said to
abate the pain, and meliorate the appearance of the sore; but, in this
respect, it seems to be very much on a level with cicuta.
Tar ointment, gastric juice, absorbent powders, and many other
applications, which it is unnecessary to enumerate, have been proposed;
but as their utility is by no means evinced, I shall not detain the
reader with any remarks upon them.
Caustic, and escharotic preparations, have been already considered.
Upon the whole, when the ulcer does not admit of being extirpated, all
which can be done, is to keep the sore clean, by washing it carefully,
and dressing it with some mild ointment, or using some of the poultices
or lotions already mentioned, if these do not gall the skin, at the
same time that we keep the patient easy by administering opium.
* * * * *
Having now concluded these observations on the cancerous inflammation,
I should next proceed to the consideration of the venereal
inflammation; but the dissertations on this subject must be reserved
for another volume.