Part 16

The mild cancer was said to begin slowly, with little pain, to continue long indolent, and to ulcerate slowly: The ulcer was not very painful, and frequently healed with a scab, or remained long stationary. This evidently was not a cancerous disease, but the one which I have described above. On cutting into this tumor, after extirpation, we find it to be of a firm texture, the interstices filled with a kind oily matter, and no cavities with thickened sides in its substance.

The malignant, or true cancer, begins with a hard schirrous tumor, with frequent lancinating pain; the skin soon adheres to the gland, and becomes slightly puckered, and of a livid or leaden colour; the veins are more or less varicose, although the tumor be not large; and the nipple, when the disease is in the breast, is generally drawn inward. The integuments next become red, and a small opening forms, through which is discharged a bloody serous-looking matter, generally in very considerable quantities. The ulcer which succeeds this is, at first, superficial, affecting only that part of the integuments which covered the pointing of the glandular cyst or abscess. It is dark coloured and fiery, like phagedena; but the edges are hard and ragged, and overlap irregularly, in different spots, small parts of the surface of the sore. In the course, however, of a few days, sometimes in a few hours, a fungus protrudes, and increases more or less rapidly, at the same time that the sore spreads laterally. This fungus is very irregular, of a dark colour, and covered with sloughy-looking pellicles. It generally sprouts out most toward the circumference, so that the sore has often the appearance of the mouth of a trumpet; or if the cavity in the middle be less, the fungus being less turned out, it resembles a cauliflower. This fungus uniformly projects over the margins, which are hard and red. The matter discharged is thin, bloody, and exceedingly fœtid. On examining these glands, we find them, in the commencement, to be hard, like a substance intermediate betwixt gland and cartilage, and of an indistinct granulated structure. Soon afterwards, we perceive small abscesses or cavities in different parts, which are filled with a serous fluid, and the sides of which are hard and firm, like gristle. These enlarge gradually, and new ones form; so that were we to cut the gland, we should find it containing a great number of these cavities[113]. Those which are nearest the surface of the gland, generally enlarge most; and sometimes only one gains any considerable size. Before this bursts, its sides become more opake, and more blended with the rest of the gland, (which, where it surrounds the abscess, becomes softer, rather more vascular, and more porous or spongy than in other parts, and than it formerly was), unless it distend beyond the substance of the gland, pushing the skin outward. In this case, when it bursts, a great quantity of lymphatic matter is discharged, and the part collapses, and then exhibits the usual appearances of the cancerous ulceration: But, more frequently, we find the abscess remain altogether in the gland, and only distend the skin a little at the apex, where it points. When the abscess bursts, more or less fluid is discharged, and immediately the inner surface begins, like the orifice, to ulcerate. A fungus is produced from the sides of the abscess, which fills up the cavity, and then protrudes from the orifice. We, therefore, find, that when the cancerous abscess bursts, the orifice at first assumes the appearance of a cancer which begins in the cutis[114]; but very soon a fungus protrudes, and the ulcer gradually becomes more convex, or more like a cauliflower.

[113] These are sometimes very irregular in their shape, and have their sides very thin; so that, at first sight, they appear like cavities formed by the separation of the fibres of the part.

[114] That is to say, the sore is rather flabby than fungous; for cancerous ulcers which begin superficially, and without previous abscess, remain a considerable time without forming fungus; but when an abscess bursts, and the skin ulcerates in consequence, then the sore is not superficial, but communicates with the abscess, which forms fungus quickly.

These abscesses, with thick sides, are characteristic of cancer, and are never found wanting in a cancerous gland. When they are not present, we may be certain, that the tumor is a different kind of schirrus. But although these be always found in the glands, and form in them a certain mark of cancer, yet they are not necessary to the existence of that disease; for the cancerous ulcer, like common ulcers, may begin without previous abscess, as we observe in the cancer of the skin, which, in nine cases out of ten, begins with excrescences like warts.

By attending to these circumstances, we may generally form a pretty just diagnosis. At the same time, it must be admitted, that, occasionally, cases do occur, in which it is impossible to deliver a decided opinion: Nor is it doubtful, that many ulcers are considered as cancerous, which are of a different nature, and some of which admit of a cure. In forming our judgment, we must be directed by the nature of the first symptoms, and the history of the schirrous stage; by the appearance and aspect of the fungus, and the other circumstances which have been already described.

Concerning the peculiar state of the parts in cancer, or the proximate cause, many opinions have prevailed; but these, however they might differ in certain points, have almost unanimously agreed in admitting obstruction as the chief cause of this disease.

Until lately, the melancholic humour was supposed to be the fluid which was obstructed, and accumulated, in consequence of which it fermented, and produced a burning ulcer; and whatever promoted the generation of this humour, was currently admitted as a remote cause of cancer. Women, says Ambrose Paré, are more subject to schirrus than men; “because their liver is warmer, and their spleen being weaker, is less able to purge the blood of choler.” Grief and chagrin, by promoting the formation of this fiery fluid, were accordingly considered by the celebrated Heister, as very apt to induce the “cancerous diathesis;” and he slyly adds, by way of corollary, that “old maids, and women who do not breed, are very subject to cancer in the breast[115].”

[115] Heister’s Institut. Vol. I. p. 229.

Concerning the particular changes which took place in the nature of this obstructed humour, many different opinions prevailed. Some thought it necessary, that the black bile should be charged with an acid, and that this produced ulceration, when “its sharp cutting points had surmounted and destroyed the volatile smegmatic and balsamic salts of the blood.” Others conjectured, that by an “adustion or over-concoction,” it grew sharp and burning: But Wiseman observes, that it is more probable that it becomes somewhat arsenical. It would, however, be useless to enumerate the different changes which this imaginary humour was supposed to undergo. It is sufficient to observe, that these were almost universally believed to depend upon the previous stagnation, in consequence of obstruction; and this leading point has uniformly been insisted on by every succeeding author, whatever might have been his particular notion with regard to the nature of the obstructed fluid, whether bile, blood, or lymph; and even the anatomical structure of the part has been brought in support of the doctrine of obstruction. One of the latest writers[116], though he talks nothing of “coagulating acids[117],” yet insists fully on this mechanical cause as the origin of cancer; “for,” says he, “the circulation in the glands being carried on by a set of vessels much more minute than those with which other parts of the body are supplied, (let this be proved), obstruction will much more readily and easily occur in them than in other parts.”--“When the substance of a gland happens to be the part, a determination is made to this, being neither, as is found by experience, so proper as the cellular substance, or the formation of pus, nor, from its softness[118], so susceptible of inflammation, as a membrane; an indolent hard swelling, called a schirrus, comes, merely by the _obstruction_ and _distension_[119] of its different vessels, very naturally to be produced.”

[116] Bell on Ulcers, p. 319.

[117] Dioni’s Chir. p. 248.

[118] Does inflammation depend upon the hardness or softness of the inflamed part?

[119] One should expect, that the distension of the vessels would diminish the cause of obstruction, or remove it altogether.

It is rather unlucky, that the advocates for obstruction have made it the cause of simple inflammation, scrophula, cancer, &c.; and therefore all these diseases ought to be nearly, if not entirely, similar in their nature, and to require exactly the same means of cure.

Some surgeons, perhaps from a desire of singularity, or from a defect of their organs of sight, declared, that they had detected little worms in the parts, which, eating it up, produced all the disagreeable symptoms of cancer; and that to their introduction the disease was owing. The cure which they confidently proposed, was applying a piece of cold veal to the part, which would tempt the animals to quit their devastation. Others, perhaps originally from ridicule, though latterly in sober earnest, told their readers, that there were no worms, but a little wolf in the part, which might be made occasionally to show its head, by holding a piece of meat before the ulcer.

Strange as this doctrine of living creatures producing cancer may appear, it is nevertheless adopted by a late very ingenious writer. When hydatids find their way into “a solid substance,” the consequence, in his opinion, will be cancer; and the success of an operation will, he conjectures, depend, in a great measure, upon these animals being confined in a common cyst, for then they may be all removed; whereas, if they be unconnected, some of the smaller ones may be allowed to remain[120]. From the surface of the cyst, which contains the animal, a fungus shoots out, and thus acts as a barrier between it and the skin; or, if the animal have been in the stomach, it separates it from the coats of that viscus, “preventing suppuration in the one instance, and absorption in the other[121].” This suppuration, “and disposition to fungate before the skin is broken,” if I understand him, is produced by the death of the animal; for, says he, “if hydatids possess the principle vitality during their transparent state, and their opacity is the effect of the loss of that principle, would they not, in the latter stage, stimulate the part in which they are situated to suppuration, as we find the case with the Guinea worm when dead[122]?” Concerning the manner in which these animals produce the symptoms of cancer, we are told, that “this enlargement of a foreign body, in a solid substance, and so extremely sensible as the breast, cannot but be attended with intense pain, and frequent inflammation[123].” A doctrine not far removed from that taught in the humoural schools, which maintained, that the coagulation and inspissation of the fluids distended the follicles of the glands, producing many cavities, and much pain[124].

[120] Adam’s Observations on Morbid Persons, p. 184.

[121] Idem, p. 185.

[122] Adam’s Observations on Morbid Persons, p. 184.

[123] Idem, p. 161.

[124] Van Swieten’s Commentaries, article Cancer.

That hydatids _may_ be formed on a cancerous gland, I shall not dispute; but that they are generally to be met with, or are in any respect essential to the disease, I cannot admit. In all the cancerous breasts, testicles, and tumors, which I have examined, I never saw any thing which could be considered distinctly as a hydatid; so that I suspect, that under this name have been described the small cancerous abscesses, with thick cartilaginous sides, which we so universally meet with in schirro-cancerous glands. We likewise find cancer take place in circumstances in which no hydatids can be found. Thus, for instance, a cancerous wart being knocked off the face, a cancerous ulcer is produced; but no hydatid is to be found at the base of the wart to produce this.

When cancer has continued some time, it was believed that the matter was absorbed, taken into the blood, and that all the humours were speedily assimilated; and it was by this absorption and assimilation that they explained the fatal and rapid progress of relapses, after an apparent cure had been obtained. That matter is absorbed, is an undeniable fact; but the only effect which is produced by this, is on the lymphatic glands[125], which intervene betwixt the sore and the heart; for, beyond these, the matter does not pass qua virus, but is changed in its nature and properties, as is the case with every other part or production of the animal, which is absorbed and formed into part of the blood. Neither cancerous matter, nor variolous matter, nor syphilitic matter, ever are formed in the blood, or ever can enter into it, unless by means of an wounded vessel. This point I shall consider more fully, when I come to treat of the venereal inflammation. Here I shall only observe, that were the reverse true, then the contagious matter must pass through every gland, and every portion of the human form, in as much as the blood circulates in every point; and, therefore, every spot should become diseased, and every part, in the same circumstances, should become diseased at the same moment[126]. Disease is not spread in the living system mechanically, by the absorption of matter, which is conveyed over the whole body, but by the sympathetic connection of parts, which has been already explained, and which will afterwards be farther illustrated. It is in consequence of this, that a distant part shall become diseased, and yet all the rest remain healthy; and even where every part becomes affected, and a general disease is suddenly produced from a local sore, as, for instance, in small-pox, there is no diffusion of matter, nor is it ever conveyed beyond the lymphatic glands.

[125] Mr. Hunter supposes, that the mere absorption of schirrous substance before matter be formed, will affect the glands; but it is difficult to ascertain the certainty of this, as small abscesses are formed very early. I have formerly mentioned, that every part of the animal is changed in its nature, at the moment of being absorbed: If so, schirrous substances lose all specific property, and cannot affect the glands. Pus, again, being a foreign matter, is absorbed unchanged, and continues so until it reaches the glands.

[126] It may be said, that different parts have different susceptibilities of assuming the morbid condition; that the bones are longer of becoming affected than the soft parts, &c. Admit this, and still it must be explained, why every part of a similar structure, &c. should not be affected at the same moment. All the glands should become diseased at once; all the bones should inflame at the same time; and, instead of finding one or two organs affected, in consequence of the previous existence of a local disease, we should find the whole system rapidly becoming diseased.

In this particular complaint, the consequence of sympathetic action, or the propagation of action, is sometimes the induction of the same disease in other parts; but most commonly the effect is the establishment of the hectic, or diseased formative action; for an explanation of which I refer to the dissertation on simple inflammation.

By examination, we find, that, in many instances, cancer is evidently produced by the same causes which are capable of producing simple inflammation; and, in every instance, I apprehend, that although the causes may be obscure, yet they are exactly of the same nature. It is, however, a general opinion, that this disease arises frequently from some unknown and mysterious cause which we cannot detect, and which, therefore, has been resolved into some constitutional taint, or cancerous ferment. But, so far as we know, the constitution is perfectly healthy in the commencement of this disease; nor is there the smallest of that it resembles scrophula, in depending upon any peculiarity of constitution, before the causes operate.

Blows, bruises, and other exciting causes of inflammation, are apt to produce cancer; but, in many instances, we can detect no evident local cause acting directly on the part. In the breast, for instance, we frequently perceive cancer commence without the interference of any topical agent. In these cases, however, we may uniformly detect an irregularity or disappearance of the menstrual secretion. It was formerly observed, that the uterus and mammæ exhibited very powerfully the sympathy of equilibrium; and it is upon this doctrine, which it is unnecessary farther to illustrate, that we are to explain the affection of the breast, which so frequently takes place in consequence of the cessation of the menses; for when the active state of the uterus is lost, the action of the mammæ is preternaturally increased, and a species of slow inflammation is induced. It is upon this principle only that we can explain why cancers are so frequent at the cessation of the menses[127]. It is ridiculous to suppose that this discharge acts as a drain to the constitution, and carries off impurities, which would otherwise collect elsewhere, and produce local diseases. The breast is almost the only organ which becomes thus affected without any agent acting directly upon the part alone; for, in most other instances, we may detect the operation of such causes at least as tend to induce simple affections of the same part; but, in both instances, the modus operandi of the cause is alike, only circumstances are somewhat varied.

[127] It was supposed, that when the menses were obstructed, the impurities were sent by communicating vessels to the breast, where they lodged, and produced cancer. Vide Vesalii Opera, p. 1092. Fabricius de Tum. p. 118.

Le Dran observes, that when schirrus, from any cause, takes place in the breast, before the cessation of the menses, it uniformly becomes more painful when any irregularity of that discharge occurs. Vide Memoires de l’Acad. de Chirurg. Tom. III. p. 22.

When the inflammatory action is slowly induced, whether by a bruise, or any other cause, acting directly on the part, or by sympathetic union with another part, we find, that the tumor which is consequent to this, seldom manifests a disposition to remove quickly, or assume the healing process. The part neither performs any distinct and acute inflammatory action, nor does it resume its natural condition and appearance, but remains in a new state, different from either, which I will call the state of simple schirrus[128]. If this state, which may follow the application of the common exciting causes of inflammation in any part, take place in cellular substance, or similar parts, which are possessed of no glandular structure, then a chronic tumor is produced, which is either slowly diminished by absorption, or at last unable to carry on its actions in perfection, being, in some respect, insulated, and deprived of the support of the surrounding parts[129]; a diseased action, or morbid performance of its actions, takes place; a slow inflammatory condition is produced[130], and at last ulceration succeeds. This, in general, forms pseudo-cancer, provided that the constitution be simple, that is to say, healthy: But if it take place in a scrophulous habit, the tumor is apt to become scrophulous, having its morbid actions modified by the morbid condition of the system. If this event take place in a lymphatic gland, instead of the cellular substance, then the tumor is still more apt to become affected with scrophulous inflammation, in consequence of even a very trifling scrophulous modification of the habit. If this state be produced in a secretory gland, the affection is somewhat different from that in simple parts, or those which do not secrete; because the inflammatory action becomes somewhat modified by the natural secreting action of the part; and, in this point of view, the gland may be considered as possessing a specific constitution, although the general constitution be simple; for, naturally possessing a peculiar mode of action, it follows, that new actions induced in such a part, ought to be performed in a different manner from the same actions in parts which naturally do not possess this peculiarity, and that the actions ought to be specifically different. When these parts are attacked with acute simple inflammation, it differs from inflammation in the cellular substance in certain circumstances, and particularly in being much more tedious; but when the nature of the part is still farther altered by the accession of a slow inflammatory action, which operates in the manner above described, then it assumes a specific inflammation, which ends in ulceration. The exact, or specific nature, of this, is various; and the state, which we call cancerous, is probably only one of the varieties of this morbid inflammatory action; and whether the part shall assume this variety, or some other variation, as, for instance, pseudo-cancer, depends probably upon local circumstances, which we cannot as yet detect or explain. If, however, the constitution possess any specific mode of action, the tumor generally assumes nearly the same mode; and, therefore, in scrophulous people, these tumors more frequently become affected with scrophulous inflammation, than with cancer: At the same time, if the previous change on the gland, induced by the slow inflammatory condition, have been great, the scrophulous condition, which it possesses in common with the rest of the system, becomes modified in it, in the same way as the simple condition, in healthy habits, is modified by the new or schirrous state of the gland; and, therefore, the scrophulous inflammation is sometimes different, and the ulceration more fungous than in other parts.

[128] Warts are, with regard to their power of acting, to be considered in the same light with simple schirri.

[129] See the Note to p. 354.

[130] The simple schirrus now assumes that specific mode of inflammatory action which it is to continue, and may now be called the scrophulous or cancerous inflamed schirrus.