LECTURE VIII.

[Delivered on January 18, 1859.]

THE HISTORY OF MALIGNANT DISEASES INVOLVING THE ORGANS OF MASTICATION.

MR PRESIDENT AND GENTLEMEN,

In the diseases affecting the organs of mastication which have up to the present time passed before us, we have met with none as yet which can be designated as inevitably fatal, despite the full resources of our science. To-night it is our task to consider a class of disorders on which death fattens, and before which the ablest science languishes helplessly. A sad task this, then, yet one which on account of its weight is the more enthralling.

more.

The disease is, and is fatal, by and from our ignorance. We are striving hard to remedy that ignorance, and we must strive The labours of the medical body during the last twenty years have indeed been very remarkable in regard to malignant diseases and their causes. Much has been determined as to the character of a malignant growth, and if nothing affirmative has been discovered as to the cause, much even in this direction has been learnt of a negative value. We have learnt, i.e., what are not causes. As I would do my best to set you all thinking deeply on the subject to be brought forward to-night, I shall not hesitate to place briefly before you the principal facts which have been brought to light by the labours to which I have referred.

By the term malignant diseases is conveyed in one general expression the diseases known commonly as cancerous diseases. They are not a wide group, indeed it is in a strict sense incorrect to speak of them in the plural number. There is, in a word, but one disease. The external form in which the disease manifests itself may vary, and upon such local variation we have a reason for certain names, after the same fashion as that by which we designate this man a negro, and that man an albino.

B B

But the disease is essentially one throughout, having the same general cause, symptom, course, and termination.

The essential nature of the disorder, in so far as it is presented to us, consists in the establishment in some part of the body of a series of new processes, consisting: First, in the formation, in the part affected, of a product foreign to the part; secondly, in the destruction of the normal structure of the part; thirdly, in the steady elimination from the part of a fluid or semi-fluid substance, derived from the blood; and fourthly, in the exhaustion of the system to its death from the constant loss to which it is subjected.

There is in regard to the body, as in regard to many other systems less complicate and better understood, one great law easily explained the law, I mean, of supply and demand, or of supply versus demand. In the body the supply must equal demand; the wasting tissue must be proportionately made up. Let this law be broken by ever so little, let the waste by ever so little be always greater than the nourishment, and the result is in the end inevitable. Time may be required for a marked change to be developed; but time is certain, and so is the result in the time, sooner or later the disproportion between the waste and the supply is felt, then the whole system fails, then the end must

come.

Attach no superstitious notion or mythical idea to cancerous growths. They kill by virtue of their interference with a simple physical law. Banks break by interference with the same law, and nations fail. If in the grand universe the same law were broken, all organic life would fail, and mother earth would be childless. The cancerous growth is not peculiar to any one structure of the body. It may be developed in gland, it may occur on mucous or cutaneous surface, it may occur in bone; and the three positions here noted are those in which it is most frequent. Nor is it peculiar to one special age, though it is most so after the age of thirty, and goes on after this increasing till old age; it has been known, however, to affect the infant before its birth. In the Medical Times,' vol. xxi, p. 368, for the year 1850, there is the report of a case by Mr Griffiths, in which a child, whose parents were apparently free from cancerous disease, was born with a tumour presenting near the left eye. The tumour, soft and pendulous, was of the size of a hen's egg, it involved the eye, and externally was highly vascular. tumour grew rapidly after birth, the skin ulcerated, there was discharge of foetid pus and of blood. The glands of the neck enlarged, and several bad swellings formed on different parts of the body. The infant died in convulsions at the end of four weeks, and the tumour, which is retained in the museum of King's College, showed all the ordinary characteristics of malignant disease. It weighed seven ounces and six drachms. The

The

brain and lungs were healthy, but the liver and left kidney contained malignant deposit.

A similar case is given in the 'Journal des Progrés,' tome xiv, by M. Tormele. The parents in this instance were free from cancerous disease, but the father was an old man, over eighty years of age. The cancerous tumour, which was of the kind known as fungus hæmatodes, was attached to the right parietal bone of the skull; it involved the osseous tissue, and perforated, but did not affect, the dura mater or membrane lining the cranial cavity. The child was born dead, and the brain

was found soft and infiltrated with blood.

It has been observed too, by most writers, that age stamps in some measure the character of the cancer mass. Thus hard cancer is most frequent in old persons, soft and bleeding cancer in the younger. But there are exceptions to this rule. The disease is ordinarily more common amongst women than men; this remark applies rather to cancerous formations altogether than to particular forms of cancer. In relation to some special varieties of malignant growth, the prevalence might, I believe, be traced to the male side of creation.

The disease seems to pervade all classes of living animals. It is common to dogs, it is common to many of those domesticated animals which we take as food; it even occurs in fishes. Dr Edwards Crisp once caught an enormous potbellied pike. He found the great size was due to a large fungous growth.

The characters of malignant tumours have been examined both chemically and microscopically, and subject to certain modifications resulting from position and stage of disease; the physical characters are pretty well understood. The tumour generally presents a fibrous basis, which is infiltrated with cells, nuclei, and cancer juice. There has been recently great discussion in the scientific world on the point whether or not there is any specific cancer cell. It was assumed some years ago that a peculiar cell called "candate" was diagnostic of a cancer growth. This view, after much discussion, has been set aside. Dr Henry, in a very able paper on this point, says: "That he should rather be guided by finding cells in situations where they ought not to be, than by finding any special cell. But if there is one cell more diagnostic of cancer than another, it is a large parent cell, with from three to five smaller ones in it." The cancer fluid is a creamy fluid which pervades the whole structure, from which it may be squeezed out by pressure, and contains the cells of which I have spoken.

These parts, consisting of the cancer cells, nuclei, and juice, give the softness to the cancer's growth, while the fibrous tissue or struma constitutes the basis or skeleton work of the tumour. Hardness or softness of cancer thus depends in great part upon

the relations in the tumour held by the fibrous basis and the infiltrated fluids.

The whole of these parts, again, are originally derived from an albuminous yellow fluid, which, eliminated direct from the blood, permeates all the tissues of the part, and yields the materials out of which the after structure is supplied and built up.

According to the general characteristics of the malignant growth, names are applied to it, mapping out the disease into its so called varieties. Thus in some examples the growth is hard, and the tumour is known by the term, schirrus, or hard cancer, the cancer most commonly affecting the heart and osteoid. In other cases the tumour is soft and spongy, or cheese-like, or very vascular, and to this variety the term medullary or soft cancer is applied. In a third class the cancerous product presents a surface of an ulcerative type, or, I had rather said, of a vegetative type, and such cancer is called epithetical, or villous. In the fourth set the tumour exists as a gelatinous mass, and is known as the colloid form of malignant disease.

This, however, may be stated, in reference to all these varieties, that they all have a common nature, and that they are susceptible of transformation, the one into the other. In all, a process of elimination or excretion is always present; in all, the tumour is highly vascular; in many instances the character of the tumour is simply modified by the infiltration into it of some matter or colouring principle derived from the blood. Thus, there is a class of cancer known as the dark or melanotic cancer, which derives its dark peculiarity simply from the circumstance that the tumour is infiltrated with a dark pigmentary substance derived from its vascular supply.

I have said that the structure of the cancerous growth has been studied chemically, but I regret to add that chemistry has as yet thrown but little light on the disorder. L'Heretier made three analyses of schirrus, and found many of the blood constituents, as water, albumen, fibrine, gelatin, fat, phosphorised fat, peroxide of iron, yellow pigment, and salts. Other analyses are certainly required, conducted on a new and a more determinate principle, but for these we must bide our time.

The local characters of a malignant growth then are, in short, the development of a new growth, attended by infiltration of fluid matter derived from the blood: a tendency on the part of this growth to ulcerate; and a tendency to continue giving out a fluid without any approach towards reparation.

In

In addition, there are some other local signs, very marked in character. One of these is pain. The pain arising from cancer varies according to the character and varies as to cause. schirrus, or hard cancer, the pain from the first is excruciating. A deep, frequent, lanceolating pain, which no sedative relieves, and which occasionally takes place in paroxysmal periods. In other

cases the pain, less intense, is dull and heavy. When the pain is lanceolating, it is due usually to interference with the nerves by which the part affected is supplied. When it is dull and diffuse, it is due, at least in part, to pressure and to encroachment by the diseased mass on neighbouring structures.

There is, further, one general sign which is always considered as indicative of the existence of cancerous disease. This is called the cancerous cachexia. Its signs are, a prostration of energy; often an unusual irritability of mind; a striking dusky yellow. ness of skin; these symptoms go on increasing until in wasting and pain the end arrives.

Common observation

There are different views as to the position of this general sign in relation to the local manifestation. places it as preceding the local disease.

Common observation

leads to the opinion that the cachectic state of the cancerous patient is the outward and visible sign of a general systemic derangement, upon which the cancer growth is engrafted. But it is fair to say that in some instances the cancerous cachexy is secondary in its appearance to the local disease, and that a few authorities of weight are inclined to consider the cachexy as the representation of the local disease; in the same manner as the exhaustion, the sweating, and the emaciation of consumption are the sequences of the local pulmonary affection.

To return to the local malignant disease; a various number of theories have existed at various times and amongst different men as to the nature of the affection.

Adams, Bacon, and Carmichael held a view that the disease was of hydatid growth. That is to say, in simplest terms, that the growth was a low form of organization, in which true and independent organized animals of the entozoa kind were produced. Modern microscopical science has done nothing but negative this hypothesis; there is, in a word, no ground for retaining it longer except as a curiosity in literature.

It

Broussais, Wenzel, Breschet, and many more, have assigned the malignant growth to an inflammatory source. In the part affected there is originally, argue these, inflammatory mischief, and the local changes are the upshot of this inflammation. can only be said in reference to this once widely extended view, that in accordance with our modern and more definite knowledge as to the nature of the inflammatory process, there are no points of analogy offered between simple inflammation and its results, and the formation of a cancerous mass and its consequences. A third theory has been offered which in plain terms suggests that the cancer matter is derived from the blood. The affected part is infiltrated with a diseased plasma, which has a tendency to new or vegetative growth. This view at all events supplies a reason for the constant supply of the disease and for the exhaustion which succeeds. But it is not consonant with all the