Part 15

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.