On the Cancerous Inflammation.

The cancerous inflammation generally comes in slowly, in some glandular part, which becomes rather harder, and somewhat larger106, 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 abscess107. 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.

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 foetor, 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 diarrhoea 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 cancer108. 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.

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 affection109 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 it110. 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 hectic111. 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.

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 foetor. 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 them112.

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 foetid. 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 cavities113. 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 cutis114; but very soon a fungus protrudes, and the ulcer gradually becomes more convex, or more like a cauliflower.

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 breast115.”

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 writers116, though he talks nothing of “coagulating acids117,” 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 softness118, so susceptible of inflammation, as a membrane; an indolent hard swelling, called a schirrus, comes, merely by the obstruction and distension119 of its different vessels, very naturally to be produced.”

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 remain120. 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 other121.” 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 dead122?” 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 inflammation123.” 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 pain124.

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 glands125, 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 moment126. 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.

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 menses127. 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.

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 schirrus128. 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 parts129; a diseased action, or morbid performance of its actions, takes place; a slow inflammatory condition is produced130, 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.

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 schirrus131. 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.

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 old132.

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. Monro133, 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.

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 diseased134, 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.

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 ointment135. 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 others136.

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 schirri137; 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.

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 quantity138. 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.

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 here139.

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 cancer140; 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.

Mercury141 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 speedily142; 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 venereal143, 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.

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 foetor; 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 foetor, in a degree superior to the hemlock, and give generally as much ease. This foetor 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 overlooked144. 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 foetor, which is certainly one advantage; but it never will perform a cure.

Carbonic acid has been said not only to correct the foetor, 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.

END OF VOL. II.

GLASGOW:
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AYTON COURT.