Part 17

The causes, then, of simple inflammation, when they operate slowly, or leave the part in a state neither inflamed nor healthy, give rise to a chronic enlargement, and change of nature, which I have called simple schirrus[131]. This performs, like every other part, certain actions, which are intended for its own support, and which must make a part of the general action of the system, or be in unison with the rest of the body. But as its actions are different in nature from those which any part of the body naturally ought to perform, and as originally this organ, (which, from the changes induced on it, is to be considered as new and extraneous), formed no part of the human frame, there is not that connection betwixt it and the rest of the system, which is necessary for its support. It, therefore, does not derive the same aid and support from the neighbouring parts which natural organs do, (for no part, or individual organ, can exist and support itself singly, and independent of the rest), and, accordingly, must soon come to suffer. It is unable to perform its necessary actions in perfection; they become morbid, and of an inflammatory nature. The tumor is now an inflamed schirrus; and this inflammation either assumes a modification, from the specific nature of the constitution, or from the peculiar nature of the tumor itself, which, as has been explained, is different from the healthy state of the tumid part. We have, therefore, the scrophulous, the cancerous, the pseudo-cancerous inflamed schirrus; and the symptoms of these different kinds of schirri, and the appearance of the ulceration, will, cæteris paribus, be modified by the nature of the part affected. The same disease, therefore, exhibits slight variations in different organs, as has been described in the history of cancer, and might, therefore, were we inclined to multiply distinctions, be considered as so many different diseases.

[131] Schirrus has generally been enumerated as one of the terminations of inflammation; but it cannot, properly speaking, be considered as such. There are only two kinds of termination, one in death, as, for instance, gangrene; the other in recovery, which is accomplished either directly by resolution, or indirectly by suppuration. Schirrus is not produced by a perfect and complete cessation of inflammation, but by a continuance of a low degree of inflammation, which renders the state of tumefaction which attends it natural to the part, before it goes off. This state, then, is not a termination of inflammation, but a consequence of its continuance.

This disease is most apt to take place in elderly people, (in so much that some consider it as peculiar to old age); because in them, parts sustain injury of their actions worst, or are less able to recover from them. Hence, two consequences follow: First, Simple schirrus is more easily produced, resolution of inflammation being more difficult, especially in parts which are, at all times, rather tedious in their recovery, when inflamed: Second, The simple schirrus is more apt to inflame, or have, what may be called, _its_ necessary actions impeded and deranged. It must, however, be remembered, that there is no age whatever exempted from this disease: I have seen it distinctly marked, and attended with a fatal event, in children of five years old[132].

[132] I have known two cases of this kind; in both the eye was affected. One boy had his eye extirpated; but a small part being left by the surgeon at the angle, the disease returned, and proved fatal. In another, the disease was in its incipient stage; but the relations would not submit to an operation.

It is a controverted point, how far it is possible to produce cancer by inoculation; some maintaining, that the application of cancerous matter to a sound part will induce the disease; others, that it is altogether harmless. Analogical evidence is certainly in favour of the first opinion; because the majority of specific ulcers may be inoculated, and have been so by accident. But, at the same time, it must be admitted, that there are few well established cases of this particular point. We find, however, that, like the venereal matter, the cancerous, when absorbed, induces a disease in the lymphatic glands, of a cancerous nature. We would, therefore, be led to conclude, that if the matter be capable of inducing cancer by absorption, in a distant part, it ought likewise to be capable of producing the same disease in another person by inoculation. The same be said of the spongoid inflammation, &c.

From these observations, it will, I presume, appear, first, That when a part is incapable of performing the actions necessary for its preservation in a state of health, it generally slowly assumes the inflammatory state, which goes on to ulceration; but the part being unable to support its natural action, can much less perform the actions necessary for restoration from this morbid condition, which, therefore, continues permanently and progressively increasing; that the nature of this unhealthy action is not always the same, but admits of variations dependent upon certain conditions in the previous state of the part affected, with regard to which we are greatly in the dark. Cancer, pseudo-cancer, spongoid inflammation, &c. are some of these variations.

Secondly, Cancer, and all these variations, are originally, in the strictest sense of the word, local diseases, depending neither upon any constitutional affection, nor the presence of any general cause. They do, however, in progress of time, affect not only parts in their vicinity, but also the system in general, producing, by means of sympathetic actions, specific hectic affections, as has been formerly explained, when treating of simple hectic. They likewise spread over more surface in the part at first affected, and produce the same morbid actions without variation, by means of the sympathia consociationis serpens. They also induce a similar disease in the nearest lymphatic glands, by absorption.

_Of the Prevention and Treatment of Cancer._

From what has been said, it will appear, that cancer is to be prevented by using the most vigorous means for the removal of simple schirri, upon their first appearance. Of these, local bleeding is the most powerful, and ought to be freely employed. Next to this, an issue in the neighbourhood of the part ought to be most depended on; and these two remedies must be employed early, and continued carefully. Whenever a simple schirrus arises, we ought to be on our guard, in whatever situation it may be placed; but, if it occupy a secretory gland, we require to be doubly vigilant. This, at first, is not painful, at least the patient only complains of slight uneasiness shooting for a moment through it. This circumstance too frequently prevents the patient from attending to it; for where there is no inconvenience sustained, there is little inducement to apply for assistance; and, not unfrequently, an ill-judged modesty contributes to this delay. But, although the patient may be little concerned at this period, yet the surgeon must not observe the same indolence. Aware of the dangerous consequences of allowing the tumor to follow its natural course, he will apply leeches once and again, and insert an issue as near the part as possible. The remedies called discutient have been much recommended at this stage; such as sal ammoniac dissolved in vinegar; and this is sometimes useful, but perhaps not more so than the vegetable acid by itself: When it does not interfere with bleeding, it may be usefully employed. By means of these remedies, we may frequently remove recent tumors, which depend merely upon the enlargement of an organ, without any other considerable change of structure. But it is more difficult to remove tumors which are not produced by the mere enlargement of a part, but depend upon a change of structure, or the formation of new parts; as, for instance, warts, polypi, &c. The small indolent tumors, however, which take place in the cellular substance, may sometimes be removed by the early use of these remedies.

When these means have either been neglected, or fail when employed, and the schirrus begins to inflame, there is little hope of performing a cure by either local or general applications; and extirpation affords the only chance of recovery which can be depended on. But, as it is not always at the very first certain that the schirrus has assumed the cancerous inflammation, and is not curable, the operation ought not to be advised in the first instance, or upon the very first appearance of the pain, or symptoms of commencing inflammation; on the contrary, we ought to have recourse to local bleeding, the use of issues, mild diet, and perhaps the use of cicuta; but if these remedies do not evidently arrest the progress of the disease, diminish the pain very considerably, and make the tumor perceptibly softer and less, in the course of a few weeks, we ought, without hesitation, to advise the removal of the part, which I shall presently consider.

The local bleeding is to be performed with leeches, which are preferable to the scarificator, being attended with less irritation. Three leeches may be applied to the part every second day, as has been proposed by some writers on this disease. This practice must be continued for a considerable time; and, during the intervals of bleeding, cloths dipped in cold water ought to be applied. If, in the course of a month, the tumor becomes freer from pain, and softer, we may apply the leeches only every third day, and continue this for another month, and afterwards either persist for some time longer in the same way, or repeat the application at longer intervals, according to circumstances. But if, on the contrary, the tumor become rather larger, and more painful, as sometimes happens, when the disease is farther advanced before we begin, and if the constitution suffer by the repeated evacuations, we must desist.

Issues may be formed, either by introducing a small seton superficially on each side of the tumor, or by blistering the part, and afterwards keeping it open with savine ointment. The latter of these methods is not admissible, when the disease has proceeded so far as to make the skin adhere to the gland, and become puckered; indeed, at this period, issues formed in any way ought never to be advised, unless the operation will not be consented to; because the chance of their producing a cure is very little, and we lose time by trusting to them.

Mild and spare diet has a very considerable influence over this disease, in almost every period, and contributes greatly to retard its progress. It ought therefore rigidly to be conjoined with the bleeding and issues, in the commencement of the disease, and will tend to abate the action in the part, and promote its resolution. The diet ought to consist of stewed apples, or prunes, panada, and weak broths, with bread. It has even been proposed to prohibit almost entirely the use of solid food, and to allow the patient nothing but water for the course of several weeks. This was much recommended by M. Pouteau, who was led to make trial of it by the success attending the empirical practice of an ecclesiastic. It was afterwards enforced by Callison; and more lately abstinence has been favourably mentioned by Mr. Pearson, who relates some cases of cancer, or appearance of cancer, in the uterus, in which it produced very astonishing effects, abating the pain, diminishing the swelling, and re-establishing the general health.

By means of these remedies, we may sometimes succeed in removing by degrees a schirrus, after it has evidently begun to inflame, and threatens to become cancerous. But if, notwithstanding these remedies, the disease evidently continues to increase, or if, in the course of a few weeks, they do not produce an evident effect, we cannot with propriety delay the operation, which is the most certain method of cure, and one which succeeds in a majority of instances, if early and properly performed; nor ought any other method of treatment to be proposed in opposition to it, unless in the very commencement of the inflammatory state; and it is in this period only that I propose the above treatment, unless the patient absolutely decline the operation; for when the skin becomes puckered, and the inflammation has continued clearly for a considerable time, without any measures being taken to remove it, the success of any local or general remedy is exceedingly precarious, and delay is not only useless, but frequently dangerous. It has, however, been doubted by some very ingenious surgeons, whether it was proper to advise the operation at any period, they believing, from the number of relapses, that it was almost useless; whilst others have been against the early performance of it, on the principle, that some parts already diseased might not have, at this period, become evidently affected; and, therefore, might inadvertently be allowed to remain.

The late Dr. Monro[133], from observing, that almost all the patients on whom, to his knowledge, the operation had been performed, relapsed, is inclined rather to adopt the palliative treatment, than the extirpation. He takes for granted, that, in the generality of cases, cancer depends upon some internal cause. In these cases, he is decidedly averse from the operation, and advises it only when the disease occurs owing to blows or hurts in young and healthy people. But, in considering this opinion, we are to remember, that a great many of these cases may be supposed to have been very far advanced before any operation was performed; and likewise, that the method of operating, in that period, was extremely unfavourable to a cure, the wound being kept open, and suppurations and ulceration rather encouraged than avoided. More lately, Mr. Hill of Dumfries has published an account of cases, where the operation was performed in more favourable circumstances, and of these not a seventh part suffered a relapse. The present Dr. Monro gives even a more favourable account; for, if I am not much mistaken, he observes, in his lectures, that not one-third of the cases in which he had been consulted, had relapsed. From my own observations, I cannot judge very accurately; because many of those on whom I have operated, came from parts at a great distance, and with which I had no intercourse; consequently, I could not hear of the result of those cases: But of the cases, the sequel of which I have heard, not a fifth part have relapsed; and in those the operation was performed at a period when the axillary glands had become diseased, but were not evidently so; and, therefore, were not extirpated; for, in all of them, the disease reappeared in the lymphatic glands. But, even from this relapse, the patients may be cured by a second operation. We may, therefore, conclude, that, if the operation be early performed, the majority will recover; and even although the disease should afterwards appear in the lymphatic glands, the patient is not incurable; for we frequently succeed in extirpating cancers, when the glands are very much affected before we are applied to. I have operated in cases where I was obliged to dissect the glands, from the axillary artery alongst almost all its course in the armpit, and which reached well nigh to the articulation.

[133] Med. Essays, Vol. V. p. 422.

With regard to the argument against the early extirpation, founded upon the possibility of the disease having affected parts in the vicinity, which have not yet evidently become diseased[134], I may observe, that, upon the same principle, we ought not to operate until the axillary glands swell; because they may be affected, although they be not yet evidently enlarged; and, therefore, may give rise to a relapse. If we only remove the single gland in the breast, which is hard, we doubtless run a great hazard of a relapse; but, I apprehend, that this ought never to be done, and that the whole of the glandular part of the breast ought to be removed at once; because we thus more certainly prevent a return of the disease, which we cannot otherwise, with any certainty, do. The additional pain is very inconsiderable; and we can derive very little advantage or benefit from leaving a part of the mamma behind.

[134] Pract. Obs. on Cancerous Complaints, by Mr. Pearson, p. 50.

The caustic has been proposed, instead of the knife, for the removal of cancer schirrus; but it is much less certain, more tedious, and even more painful. Instead, therefore, of recommending itself to timorous patients, this practice is still more to be dreaded than the excision, which is more terrible in anticipation, than in the actual performance of it.

The caustic most commonly, and indeed almost universally, employed, is arsenic, mixed with various inert substances, and formed into a paste or ointment[135]. This has been applied in two ways; first, directly upon the skin, covering the schirrus, and then, after this is destroyed, upon the schirrus itself, destroying it layer by layer; second, directly upon the skin, and then, instead of applying it to the gland, to put it round it on the surrounding cellular substance, and by gradually destroying this round the gland, to turn out the schirrus entire. This was the practice of Mr. Guy, who gained considerable credit by his success; and, since his time, it has occasionally been performed with success by some others[136].

[135] Arsenic mixed with sulphur, and powdered crow-foot, and made into a paste with yolk of egg, forms Plunket’s composition. Mixed with forty times its weight of powder of belladona, it forms an application which some time ago was much in repute in North America.

[136] Justamond on Cancers, p. 141. This gentleman relates a case, in which, by destroying the skin with lunar caustic, and then applying arsenic, he removed the gland. The arsenic, in this instance, was fused with antimony, in proportion of two parts of the first to one of the last. This was powdered and mixed with equal parts of powdered opium, and made into a liniment with yolk of egg.

This method, however, is liable to several material objections: It is uncertain in its issue; for, if the gland be not completely removed, the disease makes a rapid progress afterwards. It frequently happens, that some smaller glands around the large one are affected; and these are greatly irritated by the action of the caustic in their vicinity: It is more painful than the operation with the knife; and the subsequent process of healing, even granting the method to succeed in removing the diseased part, is much more tedious than when the incision is employed, and union by the first intention procured.

On all these accounts, but most especially on account of its uncertainty, the method of cure by caustic can never be sanctioned by any modern surgeon, much less can it ever be held up in opposition to extirpation by the knife.

This practice, which has had many advocates for its employment in schirrus, has been equally recommended in cases of cancerous ulcers; but here it is still less admissible; for the extent of diseased parts is generally greater; the neighbouring parts are affected to a greater distance; indurated and diseased lymphatics frequently extend from the breast to glands in the axilla. It is, therefore, next to impossible to turn out the morbid parts, as “nuclei,” by destroying the substance around them; and it is equally improbable that we shall, unless the sore be very small, and the caustic very strong, be able to make it slough off in successive layers. Farther we can propose no advantage to ourselves, from employing caustic in preference to the scalpel; because in every instance in which we can destroy the parts by means of this, we can equally safely, infinitely more speedily, and with much less pain, remove the parts with the knife. There is only one case in which caustic is useful, and that is merely as an appendage to the operation of excision. When we dissect off ulcers from parts where, owing to the want of cellular substance, the skin is not lax enough to be brought over the parts, or when so much of this has been removed, that, although lax, it cannot be made to cover it, we may find it of service to rub the bottom of the wound with lunar caustic, as we thus stop the oozing of blood, and destroy any little portions of the diseased part which we may have left.

For the purpose of destroying cancerous ulcers, many caustics and escharotics have been proposed, such as the arsenic, corrosive sublimate, lunar caustic, &c. Of these no one seems to possess a preference over the rest, if we consider only their local action; but some of them, especially arsenic, are apt to produce bad effects, and that very unexpectedly, on the constitution.

After making these remarks upon the method of cure, I shall conclude with some observations on different remedies, which have been proposed as palliatives, where the operation is not admirable, or will not be consented to, and which have even been supposed capable of changing the mode of acting altogether, and producing of themselves a cure. These remedies I shall divide into general and topical.

Of the general remedies, those which have been most frequently, and with the greatest confidence, employed, are narcotics, such as the cicuta, opium, nightshade, &c.

The cicuta is a medicine which was, at one time, in very high repute, and owed its reputation to the experimenting talent of Storck, who has written several libelli on this plant. According to him, cicuta possesses very evident powers over cancer, and has cured a great many cases; but, in less prejudised hands, it has been much less successful; and even in many of the instances adduced by Baron Storck of its utility, it is by no means proved, that the disease was really cancer. The present opinion of the public seems to be very unfavourable with regard to this medicine; and from the numerous instances in which it has failed, this opinion seems to be very just. Alongst with the proper local applications which have been formerly noticed, it sometimes is of service in removing simple schirri[137]; but I have never found it of any service when the schirrus had affirmed the cancerous inflammation, much less when it has proceeded the length of ulceration. In the last case, I have never found it even produce the temporary melioration which many talk of.

[137] If I am not mistaken, the present Dr. Monro mentions, in his lectures, one instance, in which a small schirrus appeared to be removed by it; but whether this was simple or cancerous, I do not know.

The common way of exhibiting the hemlock, is to begin with small doses, and increase these gradually, until they produce vertigo: For this purpose, we may begin with two grains of the extract, or four of the powder, recently prepared, twice or thrice a-day, and gradually increase the quantity[138]. In this way, we find that some patients have come to take an ounce of the extract daily; but if a much less quantity than this produce no good effect, we may consider it as useless to continue a remedy, which, in this dose, must injure the constitution every day that it is continued. On the continent, the hemlock has been used in the form of a bath; but it is so disagreeable, that few can be brought to use it.

[138] As different parcels of this medicine may not be of the same strength, it is prudent, when we begin a new supply, that we diminish the dose at first, if it have formerly been very considerable. By not attending to this, fatal effects have followed.