Chapter VII: Part 7

The means employed for promoting suppuration were formerly poultices of lily roots, honey, &c. alternated with fomentations prepared from pomegranate seeds, and myrrh, and cypress leaves, or, occasionally, stimulating plasters; but now the common bread and milk poultice is advantageously substituted in place of these remedies. When the process is very tedious, electricity is useful along with the poultices.

When these tumors have suppurated freely, and an abscess occupies the whole of the gland, it is useful to evacuate the matter by a small opening with a lancet, if there be no appearance of the abscess bursting quickly, and the sooner this is done the better. When this is done, a poultice should be applied until next day, the part is then to be wiped clean and dry, and a small bit of lint, spread with simple ointment, applied on the orifice. The surrounding red skin is to be dulled with powdered cerussa[100], and then covered with dry lint. A compress is to be laid over the whole, and moderate pressure employed. These applications are to be renewed every day, or twice a-day, according to the quantity of the discharge, and other circumstances; and, at each dressing, the parts may be bathed with spirit of wine. If this mode of dressing does not produce a cure, but the opening enlarges, and the surface ulcerates, we must then employ the dressings for a scrophulous sore.

[100] Keeping this skin dry has a tendency to prevent ulceration, and abate the redness and inflammation. The cerussa may sometimes be advantageously mixed with an eighth part of powdered camphire, which promotes the removal of the superficial inflammation.

When, notwithstanding the use of issues, matter is formed in joints, or, when these fail to procure the absorption of what was formed before they were introduced, then one of two things must happen; either the abscess must be punctured, or it must be allowed to burst of its own accord. In general, I believe, it is most advantageous to allow the abscess to burst, without any interference, except the continuance of the issue, or the establishment of such new ones as circumstances, particularly the situation of the pain, may point out. If, however, it were at any time deemed proper to evacuate the matter, this ought to be done with a small trocar, at different times, in the manner recommended by Mr. Abernethy for the cure of lumber abscess. This is infinitely preferable to the barbarous practice which even some surgeons high in reputation advise and make use of, I mean the insertion of a seton through the abscess of the joint[101].

[101] Bell on Ulcers, p. 471.

When the scrophulous suppuration ends in the ulcerative action, the cure is generally tedious. It is even doubted by some how far it is safe to attempt a speedy termination to the ulcer, as it is supposed, that, in this case, the disease may be driven to some other part: And so fearful are they of this dreadful event, that they are careful, by issues and new artificial sores, to continue the discharge after the original ulcer is healed.

If I have been right in my view of this disease, it will appear, that this reasoning is false, and that the practice is both useless and troublesome. Even those who propose and defend the practice, do so not upon the principles of reason and judgment, or from logical deductions from the theory which they give of the disease, but upon imaginary apprehensions. We find, for instance, Mr. Bell saying, that, “till the disease is eradicated from the habit, all that should in general be done to the sores, is, to give as free and open vent to the matter as possible[102].” From this, we should, without doubt, expect, that he considered scrophula as dependent upon some peculiar humour which was to be expelled; but just before we are told, that this disease depends upon debility, particularly of the lymphatic system; a condition which it is not customary to talk of eradicating, or rooting out, or expelling. Upon the common principles of reasoning, Mr. Bell ought only to have forbid healing the sores, until the system was strengthened, otherwise the weakness would be driven or determined to some other part.

[102] Bell on Ulcers, p. 427.

Moderate pressure, by means of adhesive plaster, conjoined with the application of cold water, is one of the best remedies for the mild scrophulous ulcer, when it is situated so, that this can be used. When it is not, then dusting the part thickly with cerussa, containing a sixth part of powdered alum, may be had recourse to. A piece of dry lint is next to be applied, and a compress bound down, with such pressure as can be used. It is sometimes useful to dip the compress in cold water, and renew it frequently.

The ceratum e lapide calaminari forms a very good dressing for this sore, when it is intended to leave it to follow its own course.

As a stimulant, the unguentum resinorum, either alone, or mixed with red precipitate, is often used; but it seldom is of service, and often makes the sore irritable. If, however, the ulcer become very indolent, this, or the citrine ointment, properly diluted[103], may be of service. The same may be said of the other common stimulating applications.

[103] This application forms a very useful remedy for the scrophulous ulceration of the eye-lids, which we so frequently meet with.

Poultices made of bread and sea water have been recommended, but seem to possess little power of accelerating the cure.

Solutions of alum, of blue vitriol, corrosive sublimate[104], of the nitrites of copper, bismuth, and silver, are sometimes useful to wash the sore with.

[104] This substance is the basis of a celebrated lotion for the face, which is sometimes useful in chronic pustules, which are frequently of a scrophulous nature. It promotes suppuration, the pustule then scabs, and, when this falls off, the part is sometimes found sound below. It is made by dissolving corrosive sublimate in an emulsion of bitter almonds.

The recent leaves of the wood sorrel bruised, and applied raw to the sore, is sometimes useful. The same may be said of cloths dipped in lemon juice, or vinegar and water.

Saturnine ointment is much employed by some, for abating heat and pain; but is inferior to compresses dipped in cold water.

Sometimes only the anterior part of a scrophulous tumor suppurates and ulcerates, and the deeper part of it remains swelled and hard. In this case, the bottom is generally covered with a slough, which comes slowly away piecemeal, and is renewed for some time, until the tumor subsides, partly by sloughing, partly by absorption, and partly by the subsidence of the remaining inflammatory action. In this case, sprinkling the surface lightly with precipitate, or blue vitriol, is of service; and this may be alternated with the common warm poultice. When the surface becomes cleaner, dry lint forms a very good dressing; and this may be covered with a pledget of linen spread with cerate. Afterwards pressure is useful.

The irritable overacting sore, or what has been called the struma maligna, is very difficult to manage, especially as it is frequently connected with a diseased state of the bones or tendons below.

The hepatized ammonia, diluted in the manner formerly mentioned, or simple ointment, mixed with opium, are sometimes of use.

Poultices of bitter almonds, beat up with a little olive oil into a fine pulp, and then warmed, occasionally relieve the pain, and make the ulcer more healthy.

Carrot poultices, or warm poultices made of bread and strong decoction of camomile flowers, are also sometimes of use.

Carbonic acid gas, or carbonated hydrogene, are sometimes of temporary, rarely of permanent advantage.

Anodynes, internally, are useful here, as in other painful sores.

In all cases of scrophulous inflammation or ulceration, it is useful to exhibit, alongst with the proper local treatment, such internal medicines, and to attend to the constitution, in such respects as may be deemed proper. Upon these points I have already made some observations.

When the local disease cannot be cured, and has induced the scrophulous hectic; when this cannot be removed by the means commonly employed, and which have been mentioned in the dissertation on simple inflammation, then the diseased part must be removed, if its situation permit. This must not, however, be rashly done, but must be delayed until we ascertain, that our remedies, general and local, (which must be used with assiduity and care), are of no avail. It is not sufficient that the hectic continues, and that other appearances are almost stationary; they ought to be augmenting, in order to justify amputation of a useful and important part; because every practitioner must have observed the recoveries which take place, even after the hectic fever has made considerable progress. On the other hand, we must not allow the constitution to suffer too much, but must interfere, whenever we perceive that our labours are fruitless, and that the hectic is regularly and progressively increasing, and the strength sinking. When this is observed, the only chance for life is an operation; and every day this is delayed adds to the risk attending it; for there is a degree of injury, more than which the constitution cannot sustain, and which will prove fatal, even although the exciting cause be removed. To fix the proper period requires judgment in the surgeon; but he may be enabled to do so, by attending carefully to the state of all the symptoms; for whenever these continue progressively to become worse, and have reduced the patient already to a state of weakness, which cannot be much increased without danger, he may consider it as impossible to delay amputation longer with any hopes of success.

Having made these observations on this species of scrophula, I shall now conclude, by shortly mentioning the mode of treatment adopted by the older practitioners.

Bleeding, which at first was made use of according to the custom of the day, was soon laid aside, on observing, that, in many cases, it was manifestly hurtful, and in every instance useless. But although the plan of general depletion was given up, yet local evacuations were much insisted on; for they held it as absolutely requisite, that the brain should be purged of its pituita, (the redundancy of which produced the disease), by errhines, fomentations to the ears, and the application of issues and sinapisms to the head. The stomach was cleared of viscosities, by emetics of mustard or broom-seed; the bowels, by aloes; and the skin and kidneys, by sudorifics and diaphoretics.

Having thus procured a sufficient evacuation, the patient was desired to smell a pomum odoratum, composed of styrax, amber, myrrh, aloes, and many other ingredients; the vapours of which were supposed to get up to the anterior ventricles of the brain, and dry them. Hunger and thirst, by drying the juices, were decreed to be salutary. Every thing was rendered nauseous with medicine. The bread was seasoned with anise and fœnugrek seeds, and the drink consisted of decoctions of guaiac and mastic wood, which last was “a friend to the brain and viscera[105].” As a condiment to these medicated meals, Arnoldus de Villa Nova treated his patients to the burnt sponge, mixed with salt and pepper.

[105] Laurent. de Strum. Nat. p. 67.

But these, and indeed all the medicines yielded by the materia medica, were considered as trifling, and of no avail, when compared to the miraculous power possessed by the king, who, with one touch of his hand, could banish this dreadful disorder, and dry up all the sores. So valuable did this royal prerogative appear in the eyes of many, that it became a national controversy, whether it belonged to the French or English; whilst the Romish and Protestant churches reciprocally urged this prerogative of the king of the country where they were established, as a manifestation from heaven of the justice of their cause.

In France, the king touched publicly, at four dated feasts in the year, preparing himself the day before by prayer and fasting; then entering the apartment where the sick were arranged, the patients were individually presented by the chief physician to his majesty, who placed his hand upon their head, pronouncing these words, “Le Roy te touch, et Dieu te guarit.” The sick then retire, and soon find a manifest amendment. “In some the ulcers dry up; in others the swellings diminish; and, wonderful to relate, in a few days, more than 500 out of 1000 are perfectly cured!”--“Hic hœrant philosophi, cœcutiunt medici, stupet prophanum vulgus.”

Upon reading these accounts, we smile at the credulity of mankind; but we pity them, when we learn, that near a thousand every year made weary and expensive pilgrimages, from very distant countries, to purchase this imaginary benefit.

DISSERTATION VI.

_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.