Dissertations on Inflammation, Vol. 2

by John Burns

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.

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.

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].

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.