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y	NATIONAL LIBRARY OF MEDICINE Washington,D.C.	
■		
 
 
 
ON THE
RESULTS OF  SURGICAL OPERATIONS
MALIGNANT  DISEASES,
BY
S. D. GROSS,  M.D
IKY. 9
PRESENTED TO THE AMERICAN MEDICAL ASSOCIATION,

      AT ITS SESSION OF MAY, 1853.
     PHILADELPHIA:
T. K. AND P. G. COLLINS, PRINTERS.
         1853.
■ . ... •*.,> 
wo
G %$i«- 
               RESULTS

                       OF

SURGICAL   OPERATIONS,  ETC.
         PART  I. —GENERAL  OBSERVATIONS.

    § 1.  NATURE, OBJECTS, AND  DIFFICULTIES OF THE  INQUIRY.

  Two years have elapsed since the undersigned had the honour to
be appointed by this Association Chairman of a Committee on  the
Results of Surgical Operations in  Malignant Diseases.   Soon after
he was officially notified of his  election, he addressed a circular to
his professional brethren, both in the United States and in Canada,
setting forth the  objects upon  which he  desired  information, and
earnestly inviting their co-operation in the fulfilment of his arduous
and responsible labours.  In  addition  to  this, he wrote nearly one
hundred  letters to the  most prominent  surgeons and  physicians,
entreating them to communicate to  him the results of their experience
upon a subject of  so much interest and importance to the welfare of
the human family and the character and dignity of our own profes-
sion.   To the appeals thus made, the Chairman of the Committee,
he regrets to say, received hardly a dozen responses,  and not more
than half that number  embraced any  matter  calculated to impart
real value to his  report.   The  most important contributions that
have reached him are from the pens of Dr. J. Mason Warren, of
Boston, and Professor Hamilton, of Buffalo.  Interesting communi-
cations have also been  received  from  Professor Paul F. Eve,  of
Georgia,  Dr. George  A. Bethune, of Massachusetts, Professor Pope,
of St. Louis,  Dr. Tripler, of the  United States Army, Dr. Green, of
Easton, Pennsylvania, Dr. Norris  and Dr. Littell, of  Philadelphia,
Professor Mussey, of Cincinnati,  Dr. Alexander Barclay, of New-
burg, New York, and Professor  Palmer, of the  University of Louis-
ville. 
4
RESULTS OF SURGICAL  OPERATIONS
  To my young friends, Dr. William II. Miller, Dr. Alexander For-
syth, and  Dr. J. Rowan  Pirtle,  graduates of the  University  of
Louisville,  I am  indebted  for the tables  which accompany the re-
marks  on malignant  diseases of the uterus, testis, and mammary
gland.   My former pupil, Dr. D. D. Thomson,  of this city, has also
furnished me with several interesting cases of carcinoma of the lip.
  Soon after  receiving my appointment,  Professor Parker, of New
York, and  Dr. J. M.  Warren, of Boston,  kindly consented to serve
on the  Committee;  but, owing to his arduous and incessant engage-
ments,  the former of these gentlemen has  not, I regret to say, been
able to afford  me any assistance; the valuable  contribution of the
latter,  already alluded to, will be found, without any alteration, in its
appropriate place.  For the  rest of the  report I alone am respon-
sible.
  It may be proper to observe  here, that, in the prosecution of my
labours, I have generally employed, as more convenient, and better
suited to my purpose,  the pronoun "I," instead of the more common
phrase, " Chairman of the Committee."
  Having failed to obtain from the profession of the United States
a full  and  complete  expression of  their views upon the subjects
set  forth in his  circular and  in  his  private communications, the
Chairman of the  Committee, in  order to give force  and value to his
labours, has deemed  it his duty to seek information wherever he
thought it could be found.  For this purpose, he has appealed to the
ancient fathers of the  profession, and has brought himself as  it were
into close personal relation  with  the  writers of his own  times in
Europe, in the hope of being able to extract some  light that might
serve to guide the practitioner  of the present day in a class of affec-
tions that have been emphatically styled the opprobria of the surgeon
and the physician.  Like the emmet, he has endeavoured to  extract
whatever seemed useful, and to throw it into  a heap for the benefit of
the profession.   In a question  so momentous  as the present, it is
needful that the experience of ages should be brought forward ana-
lyzed, and compared, that the wheat may be winnowed from the chaff
and the result exhibited in its true character.
   Such a step must, indeed, be considered as indispensable when we
remember how many of the works of these writers find their way into
the United  States, either in their original  garb, or in the form of re-
issues.  This remark  is particularly applicable to British works, the
great majority of which are reprinted in this country soon after they
are published at  home, and which, consequently, speedily reach the 
IN MALIGNANT DISEASES.                 5
libraries of our physicians, by many of whom they become, in due
time, to  be regarded as authority, perhaps, of the highest order.
But  this is not all.   Many of these works  are used as text-books in
our schools, and thus, falling into the hands of our pupils at an age
when their opinions  are  easily moulded, create an impression which
neither time nor circumstances can efface.
   The opinions of the continental writers of Europe, especially of
the French, are hardly less authoritative with the American practi-
tioner ; for, although  their  works are  rarely translated  into our
language, yet  their contents are sure to be made known to us, at the
earliest possible moment, by our medical press, and by those  valuable
and  widely circulated periodicals,  Braithwaite's Retrospect,  and
Banking's Half-yearly Abstract.
   Our  own country is  lamentably deficient in  native  works  on
surgery; and  there is reason to believe that the few treatises which
have appeared upon the subject have  exerted but  little,  if  any,
agency in influencing and  shaping the  professional  mind of the
United States.   The Elements of Surgery, by the  late Dr.  John
Syng Dorsey,  of  Philadelphia, have long been out of print, to say
nothing of the fact that they were composed principally of materials
derived from foreign authors, as Desault, Boyer, Cooper, and the Bells;
and  the Institutes of Surgery, by Dr. Gibson, the  veteran Professor
of Surgery in  the University of Pennsylvania, although  they have
passed through numerous editions, have not, it seems to me, exerted
that wide  and controlling  sway over American  practitioners that
might have  been reasonably expected from the high position of their
author.  The minds of his own pupils, or, rather, those of the school
with which  he has been so long connected, have  been mainly the
recipients of their contents.   Few of our colleges have  recommended
the Institutes  as a  text-book to their students;  a fate  which has
been experienced  by most  of our native  productions, and which
must continue as  long  as  foreign works  are permitted  to usurp
the  rights of  our own.   American physicians  and surgeons  seem
to glory in being the slaves  of European authority in whatever
pertains  to their profession,  both  in matters of opinion and practice;
like  Esau, they have bartered  away their  birthright for  a mess of
pottage; they are unwilling to learn anything that is purely Ameri-
can ; they are too proud to  acknowledge  that anything good can
emanate from  a native author; and  too stubborn to admit  that one
man knows  more  than another.   They would rather at any time—
lest they should seem to be indebted to their own countrymen—quote 
6            RESULTS OF SURGICAL  OPERATIONS
Louis and Chomel than Drake and Chapman, or Cooper and Brodie
than Gibson and Mott.   It is a bitter humiliation to find this tend-
ency in  our  profession ; a tendency so utterly at variance with the
true spirit of patriotism, with our  national pride, and with our na-
tional advancement as a scientific and literary people.  It is mortify-
ing to  see that everything in the shape  of a foreign book, however
shallow and  indifferent, is greedily sought and patronized  to the
neglect of our own productions.
   It need hardly be said that the subject intrusted to the Committee
is one of great perplexity.   On every side, in fact,  it presents diffi-
culties which,  in the existing  state of the science, are  absolutely in-
surmountable, notwithstanding the numerous attempts that have been
made to remove them.   The information collected in this report,  if
useful at all, is so rather negatively than positively.   It shows what
has been done rather than what  has been achieved.   It proves that
this department of  the  healing art  has been more  " laboured than
advanced."    In short,  it exhibits the humiliating evidence that our
professional brethren, although they  often  wandered in  quest of
Truth, have hitherto failed to find her, and that the great subject, in
point of fact, remains precisely where it was in  the  time of Hippo-
crates, whose wonderful sagacity induced him to declare that malig-
nant diseases,  by whatever name they may be  known, or whatever
organ  they  may attack, never  forgive,  but that they are  always
incurable by the knife and escharotics, and sooner  or later destroy
their victim.
   Much of the perplexity here alluded to  grows out of the difficulty
which attends the  diagnosis  of  malignant diseases and malignant
tumours.  Few men, whatever may be the amount of  their science,
experience, and tact, are able, at all times, or in all cases, to  discrimi-
nate, with positive certainty, between these affections and those called
non-malignant, benign, or innocuous; while the great majority find
themselves  utterly  bewildered at every step of the inquiry.   It  is
not difficult, therefore, to account for the errors which are constantly
committed in practice, and to explain the reason why a tumour or
disease which one surgeon regards as malignant should  be considered
as benign by  another,  and  vice  versa.    The  daily experience of
medical men and the records of the profession abundantly verify the
truth of these remarks.  The mammary  gland  has been sacrificed a
thousand times for  diseases  supposed at  the time to be cancerous
but which, upon a more careful  examination, proved to be  nothing
but " milk-knots," scrofulous  swellings, or chronic abscesses.   A tes^ 
IN MALIGNANT DISEASES.
7
tide, affected with sarcocele, or chronic enlargement, has frequently
shared a similar fate.   There is not  a museum or private  collection
anywhere in the country that does not afford multiplied proofs of the
truth of this statement.
   M. Broca,  in an able and  elaborate article on the pathological
anatomy of cancer, in the  sixteenth  volume of the Memoires  de
VAcademie Nationale de Medecine, states that the late Dr. Blandin,
surgeon of  the Hotel-Dieu of Paris, operated, in hospital and pri-
vate practice, in 1847 and  1848, upon sixty-nine  persons, for tu-
mours that  were neither fibrous nor  adipous, and which, before the
application  of the microscope to the study of morbid structure, would
have been pronounced cancerous.   A careful examination, however,
with that instrument, enabled  Broca to determine their precise cha-
racter.   Thus, of the sixty-nine, two were fibro-colloid;  five  con-
sisted exclusively  of  fibro-plastic tissue; fifteen others,  of  which
fourteen were taken from  the  face and one from the prepuce, were
epithelial;   and eight,  removed from the breast, were simple hyper-
trophies of that organ.   Of the remaining thirty-nine patients whose
tumours were really cancerous,  eleven died  from  the  immediate
effects of the operation ;  and of the rest  who survived,  nineteen,
whose subsequent history alone could be ascertained, had  a relapse
of the malady.  M. Lebert, in his recent treatise  on cancer,  bears
similar testimony in regard to these errors of diagnosis at the Hotel-
Dieu of Paris.   M.  Cruveilhier, in a paper  read before the French
Academy of Medicine, in  1844, broadly asserted that surgeons are
continually  cutting out fibrous tumours from the female breast, which
never undergo the  carcinomatous  transformation, and which, there-
fore, might  be allowed to  remain with perfect  safety.*  "Diseases
of all sorts," says  Professor Muller, of Berlin, "have been extir-
pated for scirrhus and cancer."f
  Now, if Blandin and his colleagues are so frequently mistaken, is
it not reasonable to  conclude that others are  equally liable to err ?
The surgeons of the Hotel-Dieu of Paris are usually men  of the first
order of talents, of great scientific attainment, and of abundant ex-
perience ; and yet we have here the most undeniable proof that they
are  often unable to discriminate between  malignant and simple
tumours.  It is only by  bearing  in mind these facts that we  are
able to  account, satisfactorily,  for  the unparalleled  success  which

          #Ainer. Journ. Med. Sciences, vol. xiv. p. 230, 1847.
          | On the Nature of Cancer, by West, p. 84, London,  1840. 
8            RESULTS OF SURGICAL OPERATIONS

attended the practice of Hill, Nooth, Flajani, and a few other sur-
geons.   Who can believe,  for a  moment,  that these practitioners
were good diagnosticians,  or that many of their operations were not
performed  upon tumours  entirely benign in their character ?   To
come  to  any other conclusion  respecting them would be to impugn
the moral honesty of these men, or to assert that human nature and
human disease were different then  from  what they  are now.
  Another source of difficulty is  that  the majority  of the recorded
cases  of  malignant  diseases are  deficient in necessary details ; thus
rendering it impossible to  use them for statistical purposes.   This
remark applies both to our periodical  literature,  to our systematic
treatises  on surgery, and to our monographs on cancerous affections.
As a proof of the truth of this remark, I  may here state that one
of the most interesting, and, in other respects, valuable works of the
present  day, the .recent production of Dr. Bennett,* Professor  of
Medicine in the University of Edinburgh, hardly contains a solitary
case available to our present inquiry.  While it describes with great
minuteness the histological characters of carcinomatous and cancroid
diseases,  as they appear in different tissues  and organs of the body,
it generally takes no other notice of the patient after operation than
to say that he was  discharged cured at such  a  time; meaning, of
course, merely that his wound had healed, and not that he had been
permanently cured of his cancer;  a circumstance of which no opera-
tor can justly judge in so short a period.
  To  render such  reports valuable and available to  the interests  of
science, it is necessary that they should embody a full and connected
history of the cases to which they relate; beginning with the earliest
period of the disease, and  tracing it through all its stages to its final
termination in the  patient's temporary freedom  from relapse,  his
radical cure, or his death.  To say that  he  has been discharged
cured, when he has merely recovered from the effects of the extirpa-
tion, is absurd.  Such a statement is of no benefit to the profession ;
for it  throws no real light upon  the final  result  of the operation.
To  enable us to  do this,  the  patient should be  diligently  watched
after the operation, with a view of determining whether he remains
free from disease;  or,  if relapse  occur, when and where  it takes
place, and what influence it exerts upon the parts  and the system at
large.  Finally, there should,  in all cases, be a careful examination
of the morbid growth with the microscope,  and a minute dissection
* On Cancerous and Cancroid Growths, Edinburgh, 1849. 
IN MALIGNANT DISEASES.
9
of the body in the event of a fatal termination.  To report examples
of cancerous affections without these details, may be calculated to
throw light upon the  site,  progress, symptomatology, and  other cir-
cumstances connected with their natural history ; but they can afford
no useful information in regard to  the results of surgical operations
undertaken for their relief or cure.
  It is for these reasons that the whole  subject of operation for ma-
lignant diseases must be investigated de novo, before we can hope to
arrive  at any satisfactory conclusions respecting it.  The next quar-
ter of a century will, if practitioners are true to themselves and to
their profession, definitively settle this long agitated, important, and
momentous question.   Let every description of cases be subjected to
the knife and to escharotics;  let every circumstance, even of  the
most trifling character,  regarding  them, be  faithfully recorded; let
the morbid structure  be carefully examined with the microscope; and
finally, let the patient be diligently watched with a view to his ulti-
mate fate; and a thousand such cases, brought together and analyzed,
will forever put the matter at  rest.   All conjecture will then  cease,
and truth will stand forth, like a beacon light, to guide and  direct
the practitioner in the true path of science.
   But are we to make no use  of the facts that have been furnished
by ancient and modern  observers ?  Are we to  discard, as useless
and effete, all our so-called knowledge upon  the subject of malignant
diseases, a subject which has  occupied  the attention of many of the
wisest and ablest minds from the dawn  of medical science up to the
present  moment?   Are the results of the operations of Monro,
Desault, Earle, Cline, Cooper, Dupuytren,  Roux,  Scarpa, Dieffen-
bach, Liston, Langenbeck, Physick, Warren, Mott, Gibson, Mussey,
and others, to be repudiated as unworthy of confidence and regard?
By no means.   The labours of physicians  and  surgeons  have not
been in vain ;  but  that they  have failed to  settle the  question
intrusted  to the Committee, it would be folly to deny.   They have
elicited  important facts,  but  facts of a negative rather than  of a
positive character; facts which are but as an ignis fatuus, calculated
to mislead and entrap the young, the inexperienced, and the unwary.
All our knowledge upon  the subject must  be re-examined  and sub-
mitted to  the ordeal  of a stricter logic, and a nicer sense of  discri-
mination.   The sight is  to be  aided  by the magnifying-glass, and
the hand by the most delicate scalpel  and forceps.   Patience and
perseverance are to take the place of  haste and indifference ;  sur-
 e-eons must  be pathological anatomists, and pathological anatomists 
10
RESULTS OF  SURGICAL OPERATIONS
must be microscopists.  The cancer-cell must be  found, recognized,
and unravelled ; mere external appearances must pass for nothing.
  Let  it  not be supposed, from the above remarks, that  I would
encourage an indiscriminate resort to the knife.   By no means.  On
the contrary, I would solemnly  warn my professional brethren at
large to abstain from operation altogether, and entreat them  to unite
in sending their cases to those  men who, by their experience  and
opportunities, are fully competent to do justice  to the subject,  and
who would thus contribute  to furnish the light  necessary to a  full
and final settlement of the question.
  The duty of the Committee is to report upon the results of surgical
operations  in  malignant diseases.   What  is a  malignant  disease ?
To this question, it  is sufficiently easy to make a satisfactory reply.
A malignant  disease is one which, whatever may be its origin, situa-
tion, or structure, has a disposition,  sooner  or later, to destroy, not
only the part, organ,  or tissue which it occupies, but also the system
at large,  and, consequently, as a necessary corollary, the life of the
patient.  In other words, all its tendencies are to mischief  and dis-
organization.    It never forgives or relents;  it  never  disappears
spontaneously; and  it  is never  cured  by medication, not even by
excision,  except, perhaps, in very rare cases.
  The mere  fact that a  disease returns after extirpation does  not
prove it to be malignant.   The most benign tumour may, if  it is not
thoroughly exsected, repullulate,  or sprout again, and, in due time,
reacquire its original  bulk.  To be truly malignant, it must possess
the properties which we have  assigned to it  in the  preceding para-
graph.
  The affections which are usually arranged under this head are the
different forms of carcinoma and melanosis.   To these may be added
certain forms of tubercular diseases,  or rather, tubercular diseases of
particular organs, as of the lungs and lymphatic ganglions.   Certain
cancroid  affections,  as they have recently been  designated,  particu-
larly lupus, or noli me tangere, also  belong  to this class, and, there-
fore, require to be considered in this paper.
  I am aware that tubercular  disease is almost universally excluded
from the  catalogue of malignant  affections, and that, in assigning to
it such a position, I  lay myself  open to the  charge  of oddity  and
obstinacy, if  not positive ignorance.   But is this  a fact?  How does
the question  stand?   I will  not assert that tubercular disease is
always malignant, though its  tendency nearly always is to destroy
the parts  into which it  is deposited, or which serve as its nidus • I 
IN MALIGNANT DISEASES.
11
wish merely to say,  and  I  make  the statement with  all possible
deliberation, that  tubercular  disease of  certain  organs,  as,  for
example, the lungs, is as malignant, as unforgiving, and  as incurable
as any form of cancer of which we have any knowledge,  or of which,
in truth, we can form any  conception.  Nay,  farther, it  is not only
malignant, but eminently malignant, destroying the tissues in which
it occurs, and the life of  the patient much sooner, on  an average,
than any form of carcinoma, excepting, possibly, encephaloid in its
worst character.   But it is different when  tubercular disease shows
itself in external and accessible parts of the body.  Here, it is gene-
rally benign in its character, and amenable  to treatment, at least
comparatively speaking.
   But,  not to dwell  upon  this point, let us proceed to inquire more
particularly into the practical  part of our report;  that  is, into  the
nature of those diseases which, under the  term malignant, as com-
monly received by the profession, usually form the subjects of opera-
tion.   These  diseases are scirrhus,  encephaloid, colloid, and mela-
nosis, of which the first three constitute  the great and important
group of cancers,  carcinomatous diseases, or cancerous growths.   Of
the malignant character of these  formations  no one  entertains  the
slightest doubt; for the experience  of ages  has amply established
the fact in  the  observations  of thousands, I had almost said, hun-
dreds of thousands of physicians and surgeons.
   All carcinomatous  growths  have a peculiar structure, of which a
particular cell, now usually known as the cancer-cell, is  the  distinc-
tive feature.  This cell, for the discovery of which we are indebted to
Lebert  and other microscopic observers, has a definite form, size, and
structure,  and the faculty also  of generating other cells,  thereby
enabling the disease  to spread itself in such a  manner as  to form
tumours, varying in their  dimensions from a millet-seed to a man's
head.   These cells  are microscopic in their  character, and  the
malignity of the morbid growth is  generally in proportion to their
number and the perfection of their development.
   In addition to the cancer-cell, there is, generally, especially in the
more advanced stages of carcinoma, a peculiar milky juice, the pre-
sence of which is almost as characteristic of the disease as the cancer-
cell itself.   This fluid has long been recognized by pathologists, but
the degree of importance  to  be  attached to it, as a test of  the can-
cerous or non-cancerous nature of morbid  growths, has been chiefly
insisted upon by Lebert, Walshe, and other recent observers.
   The term cancroid has recently been applied to a class of affec- 
12           RESULTS OF  SURGICAL OPERATIONS

tions, which, as the name implies, bear a close resemblance to cancer,
but differ from it in not containing any cancer-cells and cancer-juice.
Although  capable  of contaminating  the adjacent lymphatic gan-
glions, they are generally tardy in  their progress, and comparatively
limited in their localization;  they do not, moreover, make  any serious
inroads upon  the constitution, and  they are also less liable to return
after excision.  Hence they have been often  considered as semi-ma-
lignant in  character.  They  have also, of late, been  occasionally
described under the name of  epithelial cancers, from the identity of
their microscopic appearance with epithelium; the cells in each being
the same.   The number and variety of this class of maladies are not
accurately  determined,  but  those  which are usually comprehended
under  it are certain forms  of cutaneous ulcers,  as  lupus, or  noli
me tangere, and cancer of the lip, tongue, penis, scrotum, and the
neck of the uterus.  A cancroid affection may,  during its progress,
become the seat of the true  cancerous deposit, and thus  assume the
worst forms of  malignant disease ; rapidly contaminating the neigh-
bouring lymphatic ganglions, impairing the  general health,  and
returning after extirpation.
   It was observed, long ago,  that lupus—one of the varieties of can-
croid—and cancer, although supposed to be of the same nature, were
not equally amenable to treatment.   The  former,  it was noticed,
often disappeared  under the influence of mercury and sarsaparilla,
while the latter resisted every mode of management that  could be
devised for its  eradication.   For these reasons.  Dr. Denman,* early
in the present  century, concluded  that  there is  no identity between
the causes of these affections; a conjecture,  the truth of which has
recently been fully verified  by the researches of Lebert and other
microscopists.
   It is proper to observe that the ensuing remarks are  intended to
apply  more particularly to  the various forms of cancer;  melanosis
is of comparatively  unfrequent occurrence,  and is, therefore, men-
tioned only  incidentally.   The  term  "operation," has  reference
mainly to  excision, as this has been performed  from time immemo-
rial, especially in  malignant  diseases of the breast, and is almost the
only operation thought of by the modern surgeon.   The actual cau-
tery and the ligature have long since become obsolete as  means for
removing malignant tumours; and as to the various escharotics, as
arsenic, the Vienna  paste, chloride of zinc, and acid nitrate of  mer-
* Observations on Cancer, p. 29.  London, 1810. 
IN MALIGNANT DISEASES.
13
cury, formerly so much vaunted in the treatment of these complaints,
their use seems  to be  confined chiefly to  the hands of the empirics.
One of the most able and scientific champions, of the present day, of
this  mode  of destroying  cancerous diseases,  is Mons. Canquoin, of
Paris, who has written an interesting and elaborate treatise to prove
their superior efficacy.  My young friend, Dr. J.  Rowan Pirtle, has
done me the favour to translate for me Canquoin's table, embracing
twenty-nine  cases  treated by  escharotics.  By a reference to  this
table, under the head of Malignant Diseases of the Mammary Gland,
it will be seen that nearly every instance is marked as successful.
The reader will  not fail to place his  own estimate upon Mons.  Can-
quoin's statements.

               § 2. ORIGIN OF MALIGNANT DISEASES.

   The question  has often been asked, is cancer a disease merely of
the part in which it appears, or is it  an affection of the constitution ?
As might be supposed, no uniform answer has been, or, perhaps, can
be given to this question, although it has been agitated and discussed
a thousand times  by practitioners and  medical philosophers.   The
subject is interesting, not merely in a pathological point of view, but
eminently so  in its practical relations;  and hence it  is a matter of
deep regret that there should still be such a diversity of sentiment
concerning it.  Without going fully into the consideration of it, which
my space will not  allow, it may be  safely assumed, nay, I think, it
mio-ht be easily proved, that, while the malady, using  the word  in its
genuine sense,  is,  generally speaking, of constitutional origin,  it is
also occasionally, though rarely, of a strictly local character, without
any such antecedent or concomitant,  as the term constitutional would
lead  one to suspect.  What the relative frequency of this  origin is,
the  present  state  of the science does not, unfortunately, permit us
even to  conjecture, much less  to assert.   My own belief is, and let
it be understood that it  is a mere belief, that cancer, in forty-nine
cases out of fifty, if not in ninety-nine out of a hundred, is dependent
for its production upon  a peculiar state  of the constitution, just as
we find gout, rheumatism, scrofula, and  some other affections,  to be
dependent for their production upon  a disordered  state of the general
system.   Nevertheless, who does not know that these complaints are
occasionally of a purely local origin  and  character, unpreceded, and,
for aught we can ascertain, unaccompanied by the slightest constitu-
tional vice ?  In the same manner, cancer is sometimes a strictly local 
14           RESULTS  OF SURGICAL  OPERATIONS

disease, or, as Hunter would have expressed it, a disease not in the
part, but of the part; a disease not localized  by the  system, but
primitively and essentially established by the action and management
of the part itself, without any constitutional concurrence or antece-
dence ;  consequently, without any vitiation of any kind, either of the
fluids or solids.   The  proof of this position is to be found in those
cases in which cancerous tumours, when excised, do not return; or
where, if they do reappear, repeated operations may be performed,
and the patient  survive a long  time without any evidence of consti-
tutional dyscrasy, or infection of the neighbouring  tissues.   Several
examples, bearing directly upon  this point, will be brought forward
in the progress of this paper; and there are few surgeons, of enlarged
experience, that  have not had occasion to witness the occurrence in
their own practice.
  It has been alleged that cancer  is, occasionally, a local disease,
because it is capable of being produced under  the  influence of  local
injury.   But such a conclusion is erroneous; at all events, it admits
of doubt whether such a result ever follows such a cause, unless there
is a previous predisposition, a readiness, as  it were, on  the part of
the system, to generate cancer-cells; else, why is it that external
violence, as a blow or bruise, so seldom gives rise to this  horrible and
unmanageable complaint ?  Why, in other  words,  is it  that a blow
will produce cancer in one man and not in another; or,  still farther,
why will one man suffer and a thousand escape ?
  The theory of the local origin  of cancer, not as  an occasional cir-
cumstance, but as a constant occurrence, has  had many advocates,
and is far from being exploded at the present day.  One of its most
strenuous and influential abettors, in his  day, was Sir Everard Home,
who wrote an able and interesting treatise on this disease nearly fifty
years ago.  In  the work here referred to, he  expresses the opinion
that carcinoma is in every case,  at one precise period,  local, in the
strictest meaning of the word.*  A similar view had been entertained
long previously.  Home considers  the fact as  clearly established by
the history of several of his own cases.
  Home, also, supposed that "cancer is not a disease which imme-
diately  takes place  in a  healthy part of the body, but  one for the
production of which it is necessary that the part should have under-
gone some previous change  connected with disease, "t
  The doctrine of the local origin  of cancer, as a general fact, was
* Observations on Cancer, p. 147.  London, 1805.
f Op. cit. p. 147. 
IN MALIGNANT DISEASES.
15
strenuously insisted upon in a discussion which followed the reading
of a paper on cancer, by M. Cruveilhier, before the French Academy
of Medicine, in 1844.*  On that occasion, it was contended  by a
number of the practical surgeons of  Paris, as BeVard, Lisfranc,
Blandin, Roux, and others, that this lesion is  always  first local, and
that the constitution is affected only secondarily, by  the  absorption
of the carcinomatous  poison.  Their mode of  reasoning reminds one
of that of the syphilographer, who declares, and that  very correctly,
that there can  be no contamination of the system without  previous
inoculation.  Dr. Bennettf believes that cancerous growths are for
some time purely local.  I am unable to ascertain to what extent
the idea of the local origin of cancer prevails at the  present day in
France and  other  countries.   My opinion,  however,  from all  the
information I have been able to obtain, is, that  it is  on the decline,
and that most practitioners are disposed to espouse the opposite side
of the question.   This, I think, is certainly the case in England and
in the United States.   It  need hardly be added that the  doctrine
involves important practical considerations.   To these, allusion will
be made in their proper place.
   Another question  of great  practical  importance  connects  itself
with the one just discussed.  This is, whether  a tumour, of a non-
cancerous character, may, in  its  progress, become cancerous? whe-
ther, in other words, such  a growth is capable of undergoing what is
called the carcinomatous degeneration?  It  seems to me that it is
not difficult to give a correct answer  to this question.  If the term
" degeneration" is restricted to its true and legitimate signification,
then we must reply in the  negative,  for  no tumour,  whatever  be its
structure, can, by a  mere conversion  or transformation, pass into a
malignant condition.  Such a  change can be  effected only under the
influence of a vital  process, involving the development  and actual
existence of the cancer-cell; and I cannot, for my own part, see any
good reason why a new growth, tumour,  or deposit should  be  more
exempt from such a disease than a primitive, original, or pre-existing
tissue, whatever be its structure.   Nay, indeed, may it not be sup-
posed, that the more feebly a part is organized, the more prone  will
it be to take on such a process ?  That this change does occasionally
occur  may be inferred from the circumstance that tumours, believed
to be cancerous, but which cannot positively  be proved to be of this
* Am. Journ. Med. Sciences, vol. xiv. p. 230, 1847.
f On Cancerous and Cancroid Growths, p. 232. 
16           RESULTS  OF SURGICAL  OPERATIONS

description, remain, occasionally, in a state of latency for ten, fifteen,
twenty, and even thirty years, and then, all  of a sudden, manifest  a
malignant  and destructive  action, generally followed by  the  Avorst
consequences.  Is it  possible to  keep the cancer-cell in  check for
such a length of time?   The occurrence is, perhaps, possible, but of
its probability we are entirely ignorant.   To admit more than  this,
would  be to  wander  beyond  the  proper limits  of observation and
induction.
  It would be of great practical  utility if  we knew the  origin  of
cancer, or if  we were acquainted  with the causes, local and constitu-
tional, under the influence of  which malignant diseases, properly so
called, are  developed.   But upon this subject, unfortunately, we are
entirely ignorant, nor is it likely that our inquiries concerning it will
ever lead to a satisfactory and philosophical  solution of a question
which has occupied the best minds in the profession  from  the most
remote periods of medicine down to the present time.  All that we
know, with any degree of certainty, is, that we know nothing.  Such
a confession is humiliating enough, but it would savour alike of folly
and  of knavery,  if,  in order  to  conceal  our chagrin, we were  to
attempt to  substitute ignorance for fact,  and  specious reasoning for
solid and substantial argument.  The day for  such a course is passed;
the present age is an age of progress, and an age of realities, not of
speculation and conjecture.
  Several microscopical observers have  shown  that  the cancer-cell
occasionally exists in the general  circulating mass.   But what  does
this fact  prove, granting it to  be so?  Does it prove that the cancer-
cell is originally formed in this fluid; or  is it not more reasonable to
conclude, from  our knowledge of the nature of the  blood, and the
office of the vessels in which it is contained, that it finds its way into
it through the agency  of  the absorbents, whether we  regard this
function  as being performed  by  the lymphatics alone, by the veins
alone,  or by the joint operation of  both?  If we admit the truth of
the first  of these conjectures,  then it follows, as a matter of course,
that all idea  of excising cancerous tumours  is to be abandoned, as
utterly futile.  If, on the other hand, we give our assent to the cor-
rectness  of the other  conclusion,  the picture will certainly be  of a
more gratifying character, and hope will  not be entirely  banished
from the mind  of the operator.   It seems  to be pretty generally
believed, that, when cancer  has existed for any  length of  time  in  a
particular  part  of the  body,  it has  a tendency to°contaminate the
blood; and hence the doctrine, inculcated  by so many writers and 
IN MALIGNANT  DISEASES.
17
 teachers, that the disease should be removed at the earliest possible
 moment after its formation, in order that such a contingency may,
 if possible, be averted.

         § 3.  HEREDITARY NATURE OF MALIGNANT DISEASES.

   Carcinoma is sometimes hereditary.   The occurrence, however, is,
 I am satisfied, much less frequent than is generally supposed.  Writers
 and practitioners, in  speaking and thinking of this matter, seem to
 forget that there is a difference, and that a very wide one, between
 the transmissibility of this disease from  the parent to the offspring,
 and its coexistence, or successive development, in different members
 of the same  family.   The  latter occurrence, although also very in-
 frequent, is much more  common than the former, of which my  own
 experience has supplied me with only a few examples.   Lately, I saw
 a lady  from  Tennessee with a well-marked cancer of the mammary
 gland, whose mother and  maternal aunt had died of the same dis-
 ease.   In the summer of 1850,  I prescribed for an aged female with
 a cancer of the lip, whose mother  had perished from  cancer of the
 breast, and  the father  from cancer of  the tongue.   But the best
 and most instructive instance probably upon record is that related
 by Professor Warren, of Boston, in his work on Tumours.  It occur-
 red in a family in the neighbourhood of  that city, and is given with
 circumstantial minuteness.  A  man died of cancer  of the lip ;  his
 son had a similar disease in the  breast, from which, after having un-
 dergone an operation  at the age  of sixty, he finally lost his life.  Two
 of his sisters had cancer of the  mammary gland; were operated up-
 on ;  and ultimately died  from a  relapse of the malady.  A daughter
 of one of the ladies had  a  cancer  of the breast, which Dr. Warren
 removed at an early period ; she recovered, but perished some years
 after from disease of the uterus. A daughter of the gentleman had
 a  cancer  of  the  breast, and  there is  reason to believe that  other
 members of the family were affected by the same malady.
   The paper of Dr. J. Mason Warren, accompanying this Report, pre-
 sents a remarkable case,  marked No. 15, of the hereditary predispo-
 sition to cancer developed in early life under the influence of external
injury.   In  another case, still more  remarkable, a man who died of
 cancer  of the penis, lost his  father, grandfather,  and great-grand-
father from the same disease.
   More frequently, as has  been  already  stated,  the  disease occurs,
either simultaneously, or successively, in several members of the same
       2 
18
RESULTS OF  SURGICAL OPERATIONS
family.   My own practice has afforded me a number of instances of
the kind, and there is hardly a writer on carcinoma  that does not
narrate  examples of it.   In one remarkable case in  this city, four
out of six members of one family have died of the disease;  one from
cancer of the uterus; another from cancer of the side and mamma-
ry  gland; a third  from  malignant polypus  of  the nose;  and the
fourth from  carcinoma of the thoracic viscera.  Professor Gibson*
gives an instance of  cancer  of the breast in four sisters.   The two
eldest were operated on in North Carolina, and both died from a  re-
turn of the malady.   In the third case, the excision was performed by
Dr. Gibson, and there was no relapse ten years after.   In the fourth
case, the operation was performed by this gentleman in 1835, with
every prospect of success, but the final result has not transpired.
Bayle gives a number of similar  examples.   Thus, of a family com-
posed of five  members, one had cancer in the breast, one in the face,
and one in the stomach.  In another family, the father died of cancer
of the tongue, and a son of noli me tangere of the face.  In a third,  the
malady existed in three members, respectively, in the womb, the breast,
and the neck. Finally, in a fourth family, consisting of seven members,
one died of cancer  of the bladder, another of cancer of the breast,
and a third of cancer  of the brain.f  Examples of a similar charac-
ter  are narrated by Sir Astley Cooper %  and other writers.   I shall
have occasion to revert to this subject by and by.

              § 4. LATENCY OF MALIGNANT DISEASES.

  Cancer is sometimes a latent disease; that is, after it has reached
a certain point of development, it remains in a state  of quiescence,
apparently neither advancing nor receding.  The period  of dor-
mancy varies, in different cases and under different  circumstances,
from several months  to  several years.   In  the  case  of an elderly
lady, the wife of a Baptist clergyman of this State, and the mother
of  one  child, the  malady  has continued stationary for upwards of
twenty  years;  the  tumour occupies the mammary gland, and pos-
sesses all the external characters of scirrhus, being exceedingly hard,
and the seat of occasional sharp,  lancinating  pains.  Many years
ago, this lady consulted  Professor Dudley, of Lexington, who  un-
hesitatingly  pronounced the disease cancerous, but advised against

        * Institutes of Surgery, vol. i. p. 163, 1845.
        f Diet, des Sciences Me"d. art. Cancer, t. 3, 677. Paris, 1812.
       X Lectures on Surgery, by Tyrrell, p. 263. Philadelphia,  1835. 
IN MALIGNANT DISEASES.
19
an operation.   The general health has  usually been good, and the
local  suffering has been all along very slight.   She  has recently
passed the critical period, and  still the tumour remains indolent.
  Sir  Benjamin Brodie* saw a  case where  the  cancer remained
quiescent for twenty-five years, and where  the woman  died  at  last,
not from disease of  the breast, but  from effusion  into the cavity of
the chest.  Dr. Babington, of London,  knew  an instance in which
a schirrous tumour of the breast was stationary for twenty-four years;
and  Sir Astley Cooperf attended two females, in  whom the period
of latency of this affection amounted, respectively, to seventeen and
twenty-two  years.   Mons. Leroy, in his Memoir on  Cancer,  read
before the Royal Academy of  Sciences  of Paris, in  1843, refers to
the case of  a religieuse, who laboured under scirrhus of the mamma
for twenty-five years, and who at the end of that time was able to
perform all her duties  in the hospital.  Mr. SouthJ  alludes  to  a
similar case.   Dr.  Macfarlane, of Scotland,§  has  seen instances of
ten,  fifteen, and twenty years of this  kind  of latency.   Indeed,
there is reason to  believe that  the  occurrence  is more frequent a
good deal than is generally supposed.   The fact is  not without in-
terest in its practical relations.

 § 5. CIRCUMSTANCES CONTRAINDICATING SURGICAL INTERFERENCE.

  The following circumstances are generally enumerated  by writers
and teachers as contraindicating the  removal of  malignant tumours.
A reference to the opinions of  American, English,  French, Dutch,
and  Italian authors, cited in  this Report, will show  the remarkable
coincidence of views  upon most of the  topics  comprised  under this
head.
  No operation should  be performed when the disease  is congenital,
or when it  manifests itself soon  after birth.  Under  such circum-
stances,  a resort to the knife  is  almost certain to  be followed by
relapse, and that, too, in a very short time, owing to  the fact, pro-
bably, that  the system  is saturated,  as  it were,  with the  cancerous
poison.   Cases of this  kind  are peculiarly virulent and intractable,
resisting all attempts at cure,  or frequently even at palliation, and
rapidly tending to fatal termination.   The occurrence of the disease

          * Select Surgical Works, p. 222, Phila. 1847.
          f Lectures on Surgery, by Tyrrell, p. 268, Phila.  1835.
          X Chelius's Surgery, vol. iii. p. 509,  Phila. 1847.
          \ Amer. Journ. Med. Sciences, vol. xxiii. p. 221. 
20           RESULTS OF  SURGICAL  OPERATIONS
in several members of the same family may also be regarded as con-
traindicating ablation, inasmuch as it is denotive of  a constitutional
proclivity to malignant action.
  Interference should be avoided when the disease exists  in several
parts of the body, as, for instance, when it affects the mamma  and
the uterus, or the testicle and the  eye.  Although all these organs
are accessible to the knife, yet a resort to it under such circum-
stances would be highly injudicious, inasmuch  as it cannot  possibly
eventuate in any permanent good, but, on the contrary, be almost
sure to hasten the patient's destruction.  No surgeon, however reck-
less, would think of operating when the external disease is associated
with carcinoma of an internal part.   The coexistence of  cancers in
different organs or tissues, generally denotes a  bad state of the  sys-
tem, prohibiting surgical interference.
  Operation is never resorted to, at least not  as  a  curative  agent,
when the malady has made great and rapid progress,  or when  it has
broken through its original confines, and invaded the adjacent tissues.
Thus, in cancer of the mamma, no  surgeon who  values his reputation,
or has  any regard for the welfare of his patient, thinks of interfering
where there is great bulk of the tumour, or firm adhesion of the  breast
to the  surrounding parts; where the skin  is changed in structure,
ulcerated, indurated, or dimpled;  where there is retraction  of the
nipple, or  enlargement of  the  axillary,  subclavicular,  or sternal
lymphatic ganglions; where there  is oedema, with numbness and loss
of function in the corresponding limb ;  and finally, where,  in addition
to some of the symptoms just mentioned, the features exhibit all the
evidences  of a cancerous cachexy.    The same  circumstances guide
the surgeon in carcinoma of the testicle, of the eye, lip, penis, and
extremities.  If the knife  is  ever employed when  the malady has
made such progress and such inroads, it is  with a view solely to  pal-
liation, not to cure.   Of the propriety of such a course, every surgeon
must be his own judge.
   When the disease advances very rapidly,  as it not unfrequently
does in encephaloid, breaking through its original  boundaries, and
leaping, as it were, suddenly into the surrounding tissues, it may be
assumed, as a general rule, that  ablation will be improper; or that,
if had recourse to,  a rapid repullulation will  be the consequence!
Rapid growth, constituting what some have  denominated  the acute
form of malignant action, always implies a bad state  of the constitu-
tion, and imperatively forbids surgical interference.  There is another
symptom which is equally portentous, but which has  not, I think, en- 
IN MALIGNANT DISEASES.
21
gaged sufficient attention.  I allude to the oedematous appearance of
the parts immediately around  the morbid  deposit, or at a distance
more or less remote from it.   This condition, which is seldom absent
in external carcinoma in its latter stages, is not unfrequently present,
at an early period, in encephaloid and the  hsematoid variety  of this
affection,  and always denotes  the very worst state  of  things, both
local and constitutional.   The immediate cause of this  symptom is
obstruction of the lymphatic  ganglions and vessels.   My observation
has taught me that nothing but mischief is to be expected from inter-
ference when the malady has attained this crisis.
   I find that many of the authorities which I have examined, in the
progress of my labours  as Chairman of this Committee, speak dis-
couragingly of ablation  when  the malady has  supervened  suddenly
upon suppression of the menses prior  to  the  usual  period  for the
stoppage of this discharge.  Even great irregularity of  this function
is considered by  some as a sufficient  reason  for declining  surgical
interference.   Flajani lays  much stress upon  these  circumstances,
especially the former;  and  Bayle and  Cayol stated long ago that
the period of the cessation of  the menses and  the age  of confirmed
virility are those in which the  cancerous diathesis is  apt to  exist in
its greatest intensity.*   Neither my own experience, nor that of my
friends, furnishes me with any facts illustrative of the truth or falsity
of this opinion.
   A quickened state of the  pulse, occasioned by the local irritation,
augurs unfavourably.  Excision, performed under such circumstances,
is  nearly always  followed, it  is  said, by speedy relapse; and it is,
therefore, the duty of the surgeon to discountenance it.  This point
 is  particularly dwelled  upon  by several of the older writers, but  I
 find no  authority for it among  our contemporaries  and immediate
 predecessors.
   Temperament  is supposed  to exercise  some influence  upon  the
 result  of excision, and  may  therefore be considered, perhaps,  as
 contraindicating  the operation.   Dr. Macfarlane, of  Glasgow,  ob-
 served that the disease  was more apt to reappear and  to prove dis-
 astrous after extirpation in robust females of sanguine  temperament
 than in nervous or lymphatic persons ;  and Sir Benjamin Brodie has
 found that hysterical women  are especially unfit subjects for opera-
 tion.   My impression, however, is, in  respect to the  latter writer,
 that his remark has reference not so much to the greater liability of

       * Diet, des Sciences Medicales,  art. Cancer, t. 3, p. 673,  Paris, 1812. 
22
RESULTS OF  SURGICAL OPERATIONS
this class of females to suffer from relapse as to their greater liability
to suffer from the immediate effects of the knife.   I think it is gene-
rally conceded that fat, nervous, and hysterical persons are very apt
to perish from all  operations attended with much  shock or loss of
blood, neither of which they are able to bear well.
   Latent cancers should not be interfered with.  Cases have occurred
again and again, in which, from neglect of this precaution, the patient
has lost his life, within a very short period after operation, from a
return of the disease in  its worst form.   Dr. Macfarlane* refers to
instances where persons,  after  having laboured  under  malignant
disease for  ten, fifteen, and  twenty years, with hardly any suffering,
were cut off  in a few months by an operation.   In such cases, the
reproductive  powers of the part, if not  of the system generally, mani-
fest an astonishing  activity, and the consequence is  that  the malady
soon accomplishes its work of destruction.
   It is not necessary here to insist upon the propriety of refraining
from operation when there is serious disease of an important internal
organ.  Such a complication could hardly fail  to  predispose to re-
lapse, if not to the  speedy destruction  of the patient.   Especially is
it  important that there be no organic affection of the heart  and kid-
neys, the due performance of whose functions is so  essential to the
maintenance  of  a  healthy circulation  and the efficient and thorough
depuration  of the  blood.   The  absolute necessity of avoiding ca-
pital operations, under such circumstances, has  long been  acknow-
ledged by scientific men, but has not been  sufficiently insisted  upon
in cases of malignant disease.
   Another objection that has, been occasionally alleged against  this
operation, is  the  danger which sometimes  attends  its performance.
This danger, which may be either immediate or secondary, is unques-
tionably real, though there  is no doubt that it has been much exag-
gerated.  My own  practice  has furnished me with two cases of this
sad occurrence;  in  both, the females  were  unusually fat; they lost
each  a  considerable quantity of  blood, perhaps  a pint,  during the
operation,  and in both, death was caused by erysipelas; in  one on
the sixth, and in the other on the eighth day.   Dr. Macfarlane,t of
Glasgow, lost two patients out of thirty-two operated on for the cure
of this affection;   one  died from erysipelas, and  the  other  from

  * American Journal of Medical Sciences, vol. xxiii. p. 221; also, Walshe on Cancer
238, London,  1846.
   f Amer. Journ. Med.  Sciences, vol. xxiii. p. 221. 
IN  MALIGNANT DISEASES.
23
pleurisy.   Sir Astley Cooper* met with five deaths from this cause,
in a practice extending through many years, and involving a large
number of cases.  Two of his patients perished from erysipelas, one
from  pleuro-pneumonia, one from  the immense size of the wound,
and one from  advanced  age.   Mr. Southf gives an instance which
proved fatal from hemorrhage, almost before the completion of the
excision; the breast was of great bulk, and the blood gushed out in
torrents, so that a large quantity  was lost before  it could be con-
trolled by the operator and his assistants.  The late Mr. Abernethy|
states that he has known a patient to die soon after an operation for
the removal of a carcinomatous  tumour  of no  great  magnitude,
merely in consequence of the shock imparted to the system.  He has
seen  other cases, where the  diseased state of  the wounded  parts
seemed to have been the chief cause of the speedy death of the  in-
dividual.  Dr.  Benedict,§  of Breslau,  mentions  two  cases which
proved fatal from exhaustion, out  of  ninety-eight operated on  for
carcinoma  of the mammary gland.   Sir B. C. Brodie states that he
has lost  patients from the immediate effects of the operation, and
every surgeon has had the  same misfortune.  Not a  few examples
might be  cited from the older writers, where death followed the ex-
tirpation of the mammary gland for the relief  of this class of affec-
tions; but  as  this would subserve no useful purpose, I shall omit
 them.
    Of thirty-nine persons operated on, for cancerous disease, at the
 Hotel-Dieu, and in  private practice, by the late M. Blandin, of Paris,
 seven died from the immediate effects of the excision. ||  In the Massa-
 chusetts General Hospital, at Boston, of seventy-five cases of cancer of
 the mamma five perished from the operation; two from erysipelas, and
 three from internal disease which existed at the time of the excision,
 and should have prevented  its performance. ^
    Thus it will be  seen  that excision itself is not often followed, ex*
 cept, perhaps, in Paris, by fatal results; not, indeed, nearly as often
 as some other capital operations,  such, for example, as  amputation,
 lithotomy, and the  ligation of arteries.  I am,  therefore, induced to
 believe  that it should not, in the slightest  degree, enter into the con-

       * Lectures on Surgery, by Tyrrell, p. 273, Phila. 1835.
       f Chelius's Surgery, vol. Hi. p. 541, Phila. 1847.
       % Surgical Works, vol. ii. p. 125, Amer. edition.
       2 Rust's Magazine, No. ii. vol. xUv.
       II Broca, Mem. de l'Academie de MSdecine, t. 16, p. 752, Paris, 1852.
       fl Dr. Parkman, Amer. Journ. Med. Sciences, vol. 16, p. 305; 1848. 
24
RESULTS OF SURGICAL OPERATIONS
 sideration of the case; or, in other words, that it should never of
 itself prevent the surgeon from using the knife.   It  is well-known
 that, in  certain cases and in certain circumstances, the most trifling
 operation is sometimes followed by the speedy death of the patient,
 thus humbling the pride of the surgeon and deriding  his prognosis
 As a general rule, it may be stated, I think, that fat, corpulent, and
 indolent women, with  large breasts, are more  apt  to  suffer in this
 way than any other class of persons.   They are certainly ill able to
 bear the loss of blood and the shock of the operation; and  they are
 also, according to my observation, very prone to attacks of erysipelas,
 often of  a severe and obstinate character.  With proper attention,
 however, during the operation, and a proper preparation of the sys-
 tem, the surgeon will  rarely be obliged to witness the unfortunate
 result in question.

   § 6.  REPRODUCTIVE TENDENCY OF MALIGNANT DISEASES AFTER
                          OPERATION.

   Of the reproductive tendency  of  carcinomatous diseases,  after
extirpation, or destruction by the  actual or potential cautery, writers
have made mention from  the earliest periods of medical science to
the present  time.  Hippocrates was fully aware of the fact, and
entered his protest against all operative proceedings, under the con-
viction that, however early, or well executed,  they could not possibly
afford any permanent relief, or guard the patient against a return of
his malady.   Similar views have  been  advanced by nearly all suc-
 ceeding writers.   If a different sentiment  has  occasionally  been ex-
pressed, as has happened in a  few instances, it has been by men who
have had a very imperfect  knowledge of the disease, who have been
 poor observers, or who have wilfully concealed the truth, from inter-
 ested and dishonest motives.
   The period at which relapse occurs varies  from a few weeks to a
 number of years.   On an average, it  may be  stated to  be from  four
 to six months.  Occasionally, it takes place within an almost incred-
ibly short period.   In one  of  my cases  the malady returned in less
than three weeks.   The original disease was of eight months' stand-
ing, and was  seated in the left mammary gland, which  it involved
 nearly in its whole extent; the nipple was somewhat retracted and
 there was a  slight  enlargement of one  of the lymphatic ganglions
 winch was removed in the operation.  The dissection was performed
 with much care, and  every particle  of the  morbid structure was 
IN MALIGNANT  DISEASES.
25
apparently cut  away;  the greater portion  of the wound united  by
the first intention, but a part  at the  centre remained  open, and
became the starting-point of the new  growth.  The woman, who
was about forty-six years  of age, died three months after the opera-
tion, after having endured the most horrible torments.
   Sometimes a relapse does not take place until the end of the first
year ; and in a few instances it is  postponed to a later period, as the
expiration of the second,  third,  and even fourth year.  Broca states
that about  two-thirds of the relapses  appear during  the first  six
months after the operation, and at least three-fourths before the end
of the first  year.*   I am not able  to say how far this  assertion is
borne  out  by the experience of  other  surgeons ;  but  it does  seem
to me to be more favourable than the results of the profession gene-
rally upon this subject would warrant.
   All  malignant diseases  possess this tendency to relapse after abla-
tion, but not in an  equal degree.   Encephaloid undoubtedly enjoys
it to a far greater extent  than scirrhus, and scirrhus much more than
colloid.  Melanosis, the black cancer of Alibert and Dupuytren, also
relapses with great frequency and promptness, and may be placed as
next to encephaloid in this respect.   Again, it must be borne in mind
that a genuine cancer is more certain to return  than a cancroid
affection, as well as more apt to prove rapidly fatal.
   The reproductive  tendency  of malignant disease,  especially of
that form of it known under  the name of encephaloid, after opera-
tion, may be illustrated by a reference to cases, of which I select the
following  as  examples in which  the fairest  trial was  given  to  this
mode of treatment without any ultimate advantage.
   The first case which I shall relate  is mentioned by the late  Mr. •
Allan,f of  Edinburgh, and is one of the most remarkable on record.
 The patient, in 1805, at  the age  of  twenty-three,  observed upon his
left hip a movable  and elastic  tumour,  not larger  than a hazel-nut.
About five years  afterwards, when it  had attained the  bulk of a
 child's head, it was removed by Mr. Newbigging;  the wound healed
 kindly ; and the man was apparently well. At  the  end of nine
 months, however, it began  again  to grow, and in  seventeen months
 from the time of the first  operation, it was cut  out by Mr. Russell,
 the tumour being as  big as two  fists.   The  patient remained seem-
 ingly  well for nine months, when the morbid growth returned, and

        * Me"m. de 1'Academic Nationale de Med. t. 10, p. 742.
        f Pathological and Operative  Surgery, vol. i. p. 264.  Edinb. 1821. 
26           RESULTS  OF SURGICAL OPERATIONS
gradually increased until it acquired the size of a very large mamma;
the skin was much inflamed,  and a part of the tumour was ulcerated,
protruding a dark-coloured sphacelating substance.   Mr. Allan  now
removed  it, along with the skin, leaving  a raw surface, of the dia-
meter of the  crown of a  hat, which was  completely cicatrized in a
month.   The disease was  now  apparently eradicated, for the man
enjoyed good  health,  and resumed his  work.  In seven months,
however, it again returned, and growing  more rapidly than  at any
former period, it attained in two months  nearly the same volume as
when last  extirpated.  Mr.  John Bell was next consulted, and re-
moved the tumour, now as big as the head of a child of eight years,
along with  a great portion of its integuments.  The wound healed
kindly, as before, and when  it was  reduced  down  to  the size of a
crown-piece, it was kept open as an issue, to  invite a free discharge
of matter.  The health continued good till March, 1815,  when the
tumour showed itself a fifth time.  In December, it had acquired an
extraordinary volume, and was the  seat  of a large fungus, resem-
bling a cauliflower in  appearance.   This, Mr. Allan  destroyed by
ligature in  June, 1816, with  partial  recovery of the general  health.
A year subsequently, the tumour was of  enormous  dimensions, mea-
suring three feet in  circumference  at the base; the discharge was
very profuse,  and the general health became  so much impaired that
the man died  exhausted in January, 1818, thirteen years  after the
commencement of the malady, and nearly eight years from the time
of the first operation.   All the viscera were  found to be perfectly
sound, except  the liver, the left lobe of which contained a few hard
tubercles, about the size of barley-corns.
   The next case has been furnished  by M. Broca,* and is, perhaps,
still more extraordinary.   It came under  the observation of the late
Professor Blandin, the eminent Parisian  surgeon.   In this case, the
patient had an encephaloid tumour, of the size of a turkey's  eo-o-, on
the left  side of  the trachea, which, rapidly augmenting, threatened
to destroy him in a few months.   In  1844,  when on the point of
ulcerating, it was removed.  The wound from  the operation speedily
healed.  In five months, the disease returned, and a second opera-
tion was performed, in August,  1844.   Five  months passed  without
relapse, when the tumour reappeared, and the knife was again used
in March,  1845.   The man now remained well for  a whole  year,

  * Anatomie Pathol, du Cancer, Mem. de l'Acad. Nationale de Modecine t 16 p
756. 
IN MALIGNANT  DISEASES.                27
when, rearing its head again, the morbid growth was extirpated in
April, 1846.  At  the  end of ten months it reappeared, leading to
the necessity of a  fifth operation, which was performed on the 23d
of March, 1847.  The parts were well in a few days;  and for nine
months  the patient enjoyed an immunity from his tormentor.   The
sixth operation was  performed on  the 2d of February, 1849; but
this time the wound united less promptly, and the cicatrization was
not completed till the 23d of the month.   In five months, the malady
reappeared ; the man came again to Paris, but finding  that Blandin
was dead, and being unwilling  to intrust  his case to any other sur-
geon, he went home to submit himself to his inevitable fate.   He
lingered till the  autumn  of 1850; the  tumour, in the  meantime,
forming an enormous mass, extending from the parotid gland to the
clavicle.  The signs of constitutional infection existed in the highest
degree.
   It will be perceived  from the history of this  case, that, counting
the  intervals  between  the relapses and  the operations  of which
the poor  patient  was  the victim, he enjoyed nearly four years of
health.   This  period  might, doubtless,  have been augmented, had
the man not abandoned himself  to  despair upon finding that his sur-
geon was no longer alive.  " Is this case not  sufficient," asks M.
Broca,* " in the existing state of the science, and in the absence of
any specific remedies that may hereafter be discovered, to show that
an operation for the removal of cancer ought always to be performed
whenever it is possible to satisfy ourselves that  there is no constitu-
tional contamination?"
   The  following  case, related by  M. Jobert,f  of Paris, illustrates
this tendency to relapse when the  cancer  is situated near the eye.
The patient, when first seen by this distinguished surgeon, in Octo-
ber, 1849, was forty-two years of age.  Her health  had been quite
good till 1834, when she observed  a small tumour under  the right
superciliary ridge, which, as it was the seat of severe pain, was re-
moved  in August  of that year, when only the size of  a grape-seed.
The wound promptly cicatrized.    Between  November, 1834,  and
April,  1835,  a similar tumour  was  developed at the same  spot, and
was excised along with the lachrymal gland by Cloquet.  The wound
was healed in a month, and  for two years the  parts remained well.

   * Op. cit. p. 757.
   f Gazette des Hopitaux,  1849, No. 143;  also Brit, and Foreign Medico-Chir. Rev.
April, 1850, p. 545. 
28
RESULTS OF SURGICAL  OPERATIONS
At the end of this period, while the woman was apparently in  per-
fect health, three little tumours were observed at the old cicatrice,
and gradually involved the surrounding  structures.   She bore her
sufferings for three years, when, in 1842, extirpation was performed
by Lisfranc.   The wound healed in twenty-six days.   She continued
quite well for  one year, when  another little swelling  appeared just
above the lachrymal caruncle, which was afterwards removed  by a
young surgeon.   After a respite of two years, the malady recurred
at the  cicatrice,  and finally involved the eye.  Having borne her
sufferings for four years, she at length, in April, 1849, fell into the
hands of Jobert, who extirpated the entire eye.  Cicatrization readily
occurred, but in three months the disease showed itself again, not at
the original site, but in the orbitar surface of  the inferior lid.  This,
too,  was extirpated in November, 1849, and  the  parts  perfectly
healed.
  It will thus be seen that  the poor woman, in this case, underwent
not less than six operations; and that no effort was spared, as far as
the knife is concerned, to relieve her from her  persecuting  malady.
If, as the  reporter observes, the resources of art were not  as  com-
plete  as might  be  desired, it cannot be doubted that they  have
secured to  the patient  a prolongation of her life, and several years
of tolerable comfort.  It is to  be regretted that  no mention is made
as to the fact, whether these  tumours were epithelial or  cancerous.
It is hardly presumable that they were of the latter character, inas-
much as the intervals between the relapses were, with the exception
of one, unusually long, and inasmuch as the general health remained
throughout unimpaired.  It is equally to be  regretted that we have
no knowledge of the final result of the case.
   The next case which I shall mention occurred in my own practice.
The results have been already made known,  in part, in the Western
Journal of Medicine and Surgery for 1852.   A man, aged 32, con-
sulted me in April, 1851, for a tumour of the  lower jaw, which he
had first  noticed three months ago; it was  firm, elastic, free from
pain, of a pale-red color, and attached to  the gum and jaw, extending
from the ramus to the first bicuspid tooth.  Two operations had been
 already performed  upon it, each being  followed  by rapid relapse.
 On  the 27th of April I removed the parts, along with the  corre-
 sponding portion of the jaw;  and, early in September, he wrote me
 that the disease had returned.  On the 24th of that month I operated
 upon him a  second  time, removing the whole of the new growth.
 which was about the size of a pullet's  egg, and about three-quarters 
IN MALIGNANT  DISEASES.
29
of an inch of the anterior extremity of the ramus of the bone, from
which  the  diseased  structure seemed  to  spring.   On the 31st of
August, 1852, I excised  the  ramus at the articulation, the disease
having attacked its inferior extremity.  The man remained well until
the winter of 1853, when the  disease broke out  in front of the ear,
and now forms a tumour of the size of a small fist.   It is  worthy of
remark that the general  health has been all along pretty  good, and
that the wound has always  healed well  after each operation.  A
farther account of this case will appear under the head of  Cancer of
the Jaw.
   A most extraordinary instance of this  tendency in cancer to re-
lapse after  excision, is  mentioned by Professor Sidillot,  of Stras-
burg.*  It  occurred in a woman, aged thirty-five, who had a cancer
of the knee, which had been extirpated nine times.   It was removed
for the tenth time on the 15th of July, and,  again  returning about
six weeks after, the thigh was amputated on  the 6th of November.
The limb remained sound, but the patient died, a year after the last
operation, of cancer of the lungs.f
   The subjoined case, sent me by Dr. Alexander Barclay, of New-
burg, Orange County, New York, is one of the  most remarkable on
record.
   John Nolty, aged 43,  shoemaker, of a sanguineo-nervous tempera-
ment, applied to Dr. Barclay  on the 23d of March, 1844, on account
of a cancerous ulcer, involving two-thirds of the lower lip  ; its edges
being everted, and its surface hard and irregular, accompanied with
violent, lancinating pains.  The disease had been first noticed about
three years ago  as  a wart, the origin of which was ascribed to the
use of a tobacco-pipe.   There was  no enlargement of the  ganglions
in the neck or under the chin. The parts were removed in the usual
manner, and the wound  healed by the first intention.
    The man applied again to Dr. Barclay early in December, 1845,
 on account of an immovable bony tumour  of the lower jaw, extending
 from near the symphysis  to  the angle.   It seemed to involve only
 the outer plate of the bone,  was exquisitely painful, and was accom-
panied by severe inflammation of the soft parts.  It had commenced
 about six months previously,  and had grown rapidly up to the present
 time.   The whole of the morbid mass was now removed with the saw,
 chisel, and mallet, the operator leaving the internal plate and alveo-
* Recherches sur le Cancer, Obs. 30, p. 99.
f Bennett on Cancerous and Cancroid Growths, p. 260. 
30           RESULTS  OF SURGICAL OPERATIONS
lar process of the bone, as they appeared to be sound.  The diseased
soft  structures  were also excised; the hemorrhage was  excessive;
and,  in about two weeks, the wound was completely cicatrized.
  On the 20th  of May, the patient  again presented himself  for the
purpose of an operation, which was performed on the following day,
and which consisted in the removal of the piece of bone left at the
previous operation in December, 1845.
  In eighteen months the disease reappeared in the remaining por-
tion  of the  jaw-bone.   Dr.  Barclay declining  all further surgical
interference, the man  consulted  Dr. Blackman, of Newburg, who
exsected  the portion of the bone  containing the rest  of  the molar
teeth.  The  disease, again showing itself, was now removed by Pro-
fessor Parker, of New York,  the exsection  embracing a  portion of
the ascending ramus of the jaw.
  Twelve months after this  the disease returned, and the  man again
solicited  Dr. Barclay to perform an  operation,  which,  however,  he
declined.  The  tumour increased with great rapidity,  pressing  in-
wards upon the  tongue, so as to impede respiration and deglutition.
He struggled hard for life, but became much emaciated, and  died in
June, 1851.
  In this case not less than five separate operations were performed;
that  they had the effect of  prolonging  the patient's  life,  no  one
can doubt.   Death took place about  ten years after the first appear-
ance of the  malady,  and a  little upwards of seven years after the
first operation.
  I am indebted to  Dr. Charles S. Tripler, U. S. Army,  for  the
following history of a case of encephaloid of the thigh, remarkable
for the length of time which elapsed between the  operation and the
patient's death.
  An officer of  the army, 22 years of age, of nervous temperament,
and accustomed to much exercise on horseback, noticed,  in 1841  a
small tumour, not larger than a pea, at the upper and inner part of
the thigh.   In  the  spring of 1843,  when first  seen by Dr. Tripler,
it was  of  the volume  of a small hen's egg,  somewhat  painful, and
steadily,  though slowly, increasing  in bulk.  In June, 1844, when
this gentleman again saw the case, the local symptoms were, in every
respect, worse;   and,  although the general  health was apparently
good, yet there was some evidence of the cancerous cachexy.  The
tumour was  now removed by the  knife, and was found to  weigh five
ounces and  a half;  its structure being, to all appearance, encepha-
loid.   It  was situated beneath the  femoral aponeurosis, upon the 
IN MALIGNANT  DISEASES.
31
adductor muscle, and was  partially overlapped by the gracilis and
sartorius; portions of which, as they were implicated in the morbid
mass, were necessarily excised.   The wound did well, and  the man
soon rejoined his company.  In September, 1845, while stationed at
Corpus  Christi, in Texas, he suffered with dysentery, which induced
him to visit Pennsylvania, and  quit the army.  Recovering from this
affection, he laboured for some  time under diarrhoea, though, in other
respects, his  health wa3 good.  Late in the spring of 1847, the
tumour  reappeared,  and increasing slowly, attained, by the ensuing
autumn, the volume  of a hen's egg.  In the following summer, when
it greatly augmented in bulk, extending eight inches  down the  thigh,
and causing constant pain, he consulted the late Dr.  George McClel-
lan, of Philadelphia, who refused to operate upon him ; assigning, as
a reason,  that he would not be  able to withstand the shock and loss
of blood attendant upon the undertaking.
   From this time  on the patient gradually sank, and died in June,
1849, five years after the extirpation of the original tumour.  The
secondary growth at this time, extended half way round the  thigh,
and was of great size, weighing, as was supposed, about eight pounds.
   The following facts are added in further illustration of this inter-
esting subject.
   A female, from whom Sabatier removed a cancerous tumour of the
breast,  of large size, enjoyed  excellent health for ten  years, when
she experienced a relapse.  A second operation was performed, and
the malady had not returned when the case was reported, some con-
siderable time after.  An officer, treated by the  same distinguished
surgeon, also for a carcinomatous affection of the mamma, had  under-
gone three operations, and was in good health when the facts were
published.*  Lacombe, in his work on cancer,f narrates, with much
minuteness, the case of a mantua-maker, aged 49, who was operated
upon four times for a similar  disease, and in whom no  relapse had
taken place at the end of five years.  In a discussion on  this subject,
some years ago, before the  Academy of Medicine of Paris, Professor
Roux referred to the case of a man upon whom the celebrated Boyer
had performed five successive operations for a carcinomatous  tumour
of the  left shoulder, and  in whom there was no recurrence  of the
morbid action three years after the last excision.  He was also cogni-
zant  of the  case  of a lady, in whom there was  no  trace  of  cancer
* M6decine Operatoire, t. Hi. p. 365. Paris, 1824.
| Proposition sur le Cancer, Paris, an. xni. 
32           RESULTS OF  SURGICAL OPERATIONS
 after six operations, performed, in the space of three years, by himself
 and another  surgeon,  for  a malignant  tumour  of the mammary
 region.*

 § 7. GENERAL RULES  RESPECTING THE MANNER OF CONDUCTING EXCI-
                   SION OF MALIGNANT DISEASES.

   When excision  is determined upon, it is a matter  of paramount
 importance  that it should be performed in the most thorough and
 complete manner,  in order that the parts  may be effectually guarded
 against relapse.   The  slightest atom of the new tissue, the  most
 minute cancer-cell, nay, possibly, the smallest particle of cancer-juice,
 may, if left behind, endanger a reproduction of the malady.   Upon
 this subject  there  is such a  universal agreement  of opinion, that it
 would be folly to cite any authority in its support.  The practice is
 sanctioned alike by the  dictates of common sense and the results  of
 general experience.
   It does not fall within the province of this paper to give an account
 of the methods by which malignant tumours should be removed; but
 there are a few points  to which I deem  it my duty to advert, in a
 special manner, in  connection with the subject, inasmuch as attention
 to them must exert an important influence  upon the great question
 which  I have been examining.
   The first  of these  points, and one, as  just stated,  of paramount
 consequence, is, that every  particle  of the heterologous substance
 should be removed along with the  tumour.   To accomplish this im-
 portant object, it  is necessary that  our incisions  should always be
 carried through the healthy tissues at some distance from the morbid
 deposit.  Should any part have escaped the knife in the first instance,
 it should be  traced out immediately after the extirpation of the main
 mass, and be excised with the most scrupulous exactness.  Free use
 should be made, in this  stage of the operation, of the sponge and the
 finger; of the former, for the  purpose of clearing away the blood, and
 of the latter, for the  purpose of ascertaining  the consistence  of the
 parts which  constitute the surface  of the wound.   The sight alone
 should never be trusted  in a case  of this kind, for appearances are
 much more  deceptive than  the sense  of  touch.  Not a particle of
 substance that is in the  least suspicious should be left behind.   Skin

  * Bulletin de 1*Academic de  Medecine, Mars 26, 1844; also Compendium de Chi-
rurgie Pratique, par Berard and Denonvilliers, t. i. p. 695. Paris 1840 
IN MALIGNANT DISEASES.
33
muscles, glands, vessels, nerves, and bones should all be sacrificed, if
necessary to the success of the operation.  Nay, the very atmosphere
of the  disease should be destroyed; and with this view it would be
well to adopt the  practice of the celebrated Scarpa, of removing an
amount of healthy substance equal or nearly equal to the  abnormal.
   Secondly. The  operator should always endeavour  to preserve as
much  of the  common integuments as  possible, in order to afford a
complete covering to the surface of the wound.   This rule is one of
great  importance,  and should never be  departed from.   Another
precept, of nearly equal consequence, but one which has not hitherto
been sufficiently insisted upon, is to preserve as large a quantity as
practicable of the subcutaneous cellular tissue, with a view of main-
taining, unimpaired, the cutaneous circulation. Whenever this is much
interrupted, as it necessarily must be by a very close dissection, there
is additional danger of a speedy return of the abnormal action.
   Thirdly. When only a portion  of an organ  is involved  by the
heteromorphous matter,  the rule is to remove,  not a part,  but the
whole  of it.  Thus, in cancer of the mammary gland, the  practice
invariably is to extirpate the entire organ, no  matter how small a
portion may be implicated in the disease.  Upon this point surgeons
have long since  been agreed.  When the  disease is  seated  in an
extremity, especially the distal portion, the proper operation is ampu-
tation, not excision.
   Fourthly.  In removing a malignant  tumour we  should  always
endeavour to avoid the loss of blood.  This is a good rule, I con-
ceive, even when the patient  is tolerably plethoric; but its observance
is especially important in lean and fat subjects, the latter of whom, in
particular, generally bear the loss of this fluid very badly.  I deem
it a matter of great moment to guard  against hemorrhage in every
operation of this  kind, not  so  much on  account of  the immediate
recovery of the patient as on  account of the danger of relapse, which,
I feel constrained to believe, is frequently very much increased by this
accident.
  Fifthly, and lastly.  It is a matter of great consequence,  in refe-
rence to the question of relapse, that the whole of the wound left by
the operation should  be healed by  the first intention.  For this
purpose, the  parts  should always be  approximated as  nicely as
possible, not only at their edges* but also  over the  surface  of the
wound, that there  may be no  cavities or pouches for the lodgement of
matter, but that the restorative process may  proceed in the best and
most rapid manner at  every  point.   The  best dressings, I  conceive,
       3 
34
RESULTS OF  SURGICAL OPERATIONS
are a light compress and a bandage, aided by adhesive strips, or col-
lodion plaster.  Sutures I consider as objectionable, because the track
made by them occasionally serves as a point of departure to the new
deposit, thereby promoting relapse.   We have already dwelt upon the
importance of saving a sufficient amount of integuments,  that is, skin
and cellular substance.  Any deficiency of this kind must necessarily
interfere with the adhesive process.
  When a sufficiency  of integument cannot be  preserved, and the
wound is  obliged to heal by the granulating process, it is, I think,
worthy of consideration whether the whole  of the raw surface should
not be effectually cauterized with the nitrate of silver, or with a stick
of the Vienna paste, so as to form a superficial eschar.   The practice
certainly derives support from the beneficial effects which are said  to
follow the treatment of  cancer by cauterization in the hands of the
empirics, as well as in the hands  of  certain scientific practitioners,
especially Canquoin.
  Rhazes,* the Arabian, who flourished in the latter part of the ninth
and  the  beginning of the  tenth  centuries,  and  who obtained the
appellation of the experienced, recommends that all the carcinoma-
tous structures should be retrenched with the greatest possible care;
and he goes so far even as to enjoin  that all enlarged veins,  as well
as a portion of the surrounding healthy tissues, should be removed
at the same time.   Then, as if to render assurance doubly sure,  he
cauterized  the  surface of the wound with  the red iron, and imme-
diately  after used  such  means  as were  calculated to promote the
speedy separation of the eschar.   A similar practice was afterwards
pursued by other surgeons, but with what effect has  not transpired.
I beg leave to recall the attention of the Association to  the  subject,
in the hope that it may engage their consideration, with a view  of
determining whether  this treatment,  in  some modified form, is not
worthy of renewed  trial.  In a disease which has hitherto baffled  all
our attempts at cure, and which is so prone to return after operation,
even when performed under  the most favourable circumstances, every
experiment having for  its object the destruction of the new substance
and the prevention  of its recurrence  ought to be  regarded  not only
as justifiable, but highly proper.
  Considerable diversity of opinion has existed among surgeons as  to
the  time  when the operation should be undertaken with  the best
prospect of ultimate success. The preponderance of professional senti-
* Continens, lib. xiu. cap. 2, fol. 256. 
IN MALIGNANT DISEASES.
35
ment, however, has always been in favour of early interference, on the
ground that the longer the disease is permitted to remain the greater,
all other things being equal, will be the risk of contamination.   The
advocates of this measure, indeed, never countenance a resort to the
knife when there is positive evidence that the disease has invaded the
adjacent parts, or the system  at large.  Some, it is true, employ it
with a view of prolonging life, or alleviating suffering, but never with
the hope of effecting a  radical cure.  Among those  who  advocate
the propriety and  importance of delay, no  one holds a  more con-
spicuous rank than the late Mr. Pearson, of England.  "The early
extirpation  of cancer," says this distinguished  writer,* " confers no
peculiar  security against the return of the  complaint; on the con-
trary, if the removal of the morbid  part were equally complete  in
two patients, one of whom has  been afflicted seven months, and the
other  seven  years, with a cancer, I should esteem the latter patient
in less danger of a relapse than  the  former.  My reason  for an
opinion, which  to  some  people may appear singular, is this, that
when the breast, for example, is affected by the cancer, distant parts
of that gland may  become the seat of the morbid alteration about
the same period.   These several diseased portions may not advance
with an equal celerity, but  while one portion has acquired a consider-
able bulk, the other altered parts may be scarcely objects of  atten-
tion.   Under such  circumstances  the  most  obviously  morbid parts
may be removed, but the disease, being only in progression, no man
can be certain, without removing  the whole breast, that he has not
left some diseased  fibres.   If, however,  the  disease  shall continue
without increasing during several years, one  may in general conclude
that  its boundaries are  more  accurately defined."   Similar senti-
ments have been expressed and advocated by several recent authori-
ties.
   Without  stopping to  dispute the accuracy of the opinions of the
advocates for delay, I may state, as the result of my reading, that
multiplied and reiterated experience has shown  that, in the great
majority  of  cases, if not in nearly all, the  disease, if removed at a
late stao-e, is only aggravated, and runs a more rapid course  than it
would do if left to itself.   The testimony of Dr. Macfarlane, already
alluded to, to say nothing  of that of other surgeons, is conclusive
upon this subject.  This gentleman, who enjoyed ample opportunities
of investigating the question, states  that he could adduce a number
* Practical Observations on Cancerous Complaints, p. 31. 
36           RESULTS OF SURGICAL OPERATIONS
of instances in which  patients, after having laboured under  malig-
nant disease for fifteen, and even twenty years, were cut off in a few
months by operation.  The complaint, under such circumstances, has
a peculiar repullulating tendency, owing  apparently to an increased
functional activity of the capillary vessels, and also to an increased
perversion of the nutritive process.   The operation acts, figuratively
speaking, like a blow or bruise, rousing the parts which had  served
to circumscribe the morbid growth from their  slumber, and causing
them to engage in the  formation and deposition of new cancer-cells,
with a force and rapidity previously  unknown.

                § 8. TREATMENT AFTER OPERATION.

  Another object to be attended to, after operation for the removal
of the diseased structure,  is the patient's diet.  Of the propriety and
importance of this injunction no one  can entertain any doubt.  The
force of this remark will  appear more evident  when it is recollected
that the progress of cancer has occasionally been stayed for months
and even years by a  regular and persistent system of starvation,
barely allowing a sufficient quantity  of food, and that of the most
bland and unirritant character, to  maintain the due play of the vital
functions, without too great a reduction of the  heart's  action. Pou-
teau in France, Callisen  in Denmark, and Fearon and Pearson  in
England, have  particularly insisted upon this kind of diet, asserting
that its employment is of more  service in arresting the progress of
cancer than any medicines that have ever been  suggested for the
purpose.
  The kind of diet is,  doubtless, a matter of no little moment.  As
a general rule, it may be stated, that meats, soups, and  the coarser
varieties of vegetables  should be proscribed, on account of their heat-
ing and indigestible character.   For the same reason, condiments
such as mustard and pepper, wine, spirits,  and fermented liquors are
to be  eschewed.   Among the more  suitable articles  may be men-
tioned stale bread, toast, and  soda biscuit, hominy, rice  sweet and
Irish  potatoes, mush,  macaroni, baked apples, figs, and ripe fruits.
Not only should the food be perfectly simple and easy of  digestion,
but great care should be taken that it is always thoroughly masticat-
ed, and that the quantity at each meal is never so great as to crowd
and oppress the stomach.  As drinks,  the best  articles are  water
lemonade, milk,  and weak tea.   Coffee,  as being too stimulating^
must be avoided. 
IN MALIGNANT DISEASES.
37
   Of late years, the attention of the profession  has been called to
the importance of an almost exclusively milk diet after an operation
of this kind.  The first mention which I find of  this subject  is by
Antoine  Deidier,* of Paris,  as far back as a century and a quarter
ago.  In a case of carcinoma of the breast, he attributes  the happy
issue mainly to a diet of milk, prescribed after the operation.   Some
years ago, Dr. Leonard Pierce, f of Sutton, Massachusetts, published
the particulars of a most interesting case  of cancer of  the mamma,
showing  the beneficial  effects of this  simple mode of  living.   The
patient, his  own  mother, first discovered, in September, 1825, when
in her sixty-second year, a tumour about the size of a chestnut in her
right breast.  A course of iodine, both external and internal, having
failed to  do  any good, and the tumour continuing to  increase, at the
same time that it was attended with lancinating pains, excision was
performed  on the 29th of May, 1826.   The wound healed without
any difficulty, and the  health remained as good  as  usual until the
following winter,  when another  tumour  appeared just beneath the
cicatrice, accompanied with similar pains.  This was removed, without
any previous treatment, on the 5th of April, 1827. The wound showed
but little disposition to heal, and in a few weeks two other tumours
appeared in  the neighbourhood of the former ones, and rapidly increas-
ing soon ulcerated, and finally formed  a hemispherical growth  some-
what elevated above the skin, having an exceedingly jagged and angry
aspect, bleeding on  the slightest injury, and constantly discharging
a thin, watery, irritating fluid, The pain in the part, as well as in the
axilla, was excessively severe, and almost  uninterrupted;  there was
also severe  pain  in  the uterus, and everything, in short,  seemed to
indicate that the case would soon terminate in death.
   On the 13th of  September, 1827, soon  after  a severe attack of
dysentery, which had reduced the patient very much, the  knife was
again used.   At that time the tumour was  larger than the breast,
whose place it occupied, and it had for more than two months past
bled from one to three ounces daily.  A large portion of integument
was removed  along with the tumour, the base of which was nearly
four inches in diameter; the pectoral muscle was  perfectly sound;
the wound  soon entirely  healed, partly by adhesion and partly
by  granulation; and the pains in the axilla and  uterus entirely
subsided.
  It is proper to observe—for this is the  chief motive for adducing

     * Dissertation sur la Nature et la Gue"rison des Tumeurs, Paris, 1725.
     f American Journal of the Medical Sciences, vol. viii. p. 49, 1831. 
38           RESULTS OF  SURGICAL OPERATIONS

the case—that this lady, at the  suggestion of the  late Professor
Smith, of New Haven, had  subsisted for  about two months before
the last operation upon the most  bland and simple diet, consisting
exclusively of boiled green corn,  seasoned with  salt, and cooling
drinks.   She had also employed, three times a day, a pill composed
of about three grains and a half of red oxide of iron, and one grain
and a half of extract of conium.   This prescription was  laid aside
after the operation,  but she rigidly continued her corn diet, using the
article fresh, or otherwise,  according  to  the  season  of the  year;
sometimes she ate it in the form of hominy, with molasses, or she had
it ground, and made into bread with water.
  After having used this fare for about a year, she attempted the use
of animal food, barely tasting it;  but was  obliged to  abandon it at
once, as it made her mouth and throat sore,  and produced pains in the
axilla, similar to those she had experienced in the cancer.  The trial
was several times renewed, at intervals  of several months, but always
with similar results.  Exercise and mental emotions  had the same
effect, for a considerable time  after the operation, as animal food,
and she was obliged to avoid them.  She occasionally ate fish spar-
ingly.   Potatoes agreed well with her.    This diet  was continued
faithfully up  to  the time—how long afterwards, I cannot say—of
the publication  of the case, in  March,   1831.  All animal food,
■liquors, condiments, and  heating drinks  were studiously  avoided.
She never, however, deprived herself  of the use of tea, but always
took it cool, in small quantity.  From the time  she began to  diet
herself, the alvine discharges were thin and watery,  and so continued
as long as she confined herself to green corn ; they were also hot and
excoriating.  It had the effect, moreover,  of greatly diminishing her
strength; but this  afterwards improved very much when  she  com-
menced the use  of  ripe corn, bread, and  other vegetables.  Under
this management, the health became as good  as it  had been before
she was  affected with cancer, which had not returned at the period
above referred to,  that is, about three years  and  a half from the
time of the last operation.
  Another most interesting and instructive  case of  malignant dis-
ease, exhibiting the beneficial effects of a restricted diet, occurred  a
few years ago in the  person of an honoured member of this Asso-
ciation, and  has been carefully reported by Dr. H. J. Bowditch  of
Boston.*  I allude to the  case of  the late Dr. Twitchell, of New
* Bost Med. and Surg. Journ. vol. xli. p. 494. 
IN MALIGNANT DISEASES.
39
Hampshire.  This gentleman, whose grandmother died of cancer of
the breast, and whose  sister had scirrhus of the pylorus, observed,
when nearly sixty years of age, a small, hard tumour, free from pain,
and not larger than a grain of mustard,  at the  inner angle  of the
right eye.   It  was imbedded  in the  substance  of the skin, and
seemed  little inclined  to  increase.   In  1843,  it  had  attained  the
volume of a pea, and had a tendency to form scabs, the removal of
which, under the use of Janning's eye-salve, usually exposed a small
lobulated surface, covered with a little purulent fluid.   In 1845, the
greater  portion of the tumour was  excised by  Dr. Hayward, of
Boston.  For a short time, the wound seemed to do well; but, finally,
refusing to heal, the part was removed again two months afterwards,
and  touched with nitrate of silver.   Meanwhile,  however,  it had
become  the seat of a deep-seated and rather severe pain, radiating
towards the brow and cheek, and less transitory than before.
   The tumour continued to augment slightly, and in the  spring of
1847 it exhibited a decidedly malignant aspect.   It was an ulcer,
about the size of the top of the finger, with hard, ragged, and  ele-
vated edges, and an  irritating  discharge, which at night caused a
gluing of the lids.  Dr.  Twitchell  now  determined to  diet himself
most rigidly, and for this purpose he used, three times daily, from four
to six ounces of cream or rich milk, and  the same quantity of white
or brown bread.  This  course was faithfully persevered in with the
effect of a complete cure until  1850, when the case was published.
The pains in the part were lessened almost immediately ;  the puru-
lent discharge  also soon  diminished;  and it became apparent, in a
few  months, that the  disease was not augmenting; the cure  gradu-
ally progressed, and  in August, 1848, the ulcerated mass was en-
tirely gone, leaving the angle of the eye perfectly natural, excepting
a  minute white  cicatrice,  about a line in diameter.  It  is worthy of
remark that  this rigid course  of dieting exerted no  pernicious in-
fluence upon the patient's general health; but that, on the contrary,
he presented, at the end of two years, when the cure was completed,
the picture of a hale, robust man.
   In a case of osteo-sarcoma of the scapula, in a man  about forty
years of age, a  tumour, as large as a pint-bowl, was reduced,  by this
simple kind of  diet, to such an extent that there was, at the  end of
two  years, merely a  trifling thickness of the  skin.   The disease,
when first seen by Dr. Twitchell, whose patient the man was, looked
so unpromising that  this gentleman  declined extirpation, being, in
some degree, deterred by the result of a similar case, where the in- 
40
RESULTS OF  SURGICAL OPERATIONS
dividual died, sometime after the operation, from carcinoma of  some
one of the internal organs.*
  A case of  cancer of the womb, in which the progress  of the affec-
tion appears  to have been retarded, if not arrested, for a long time,
occurred, a number  of years ago, in the practice of  Dr. James Mc-
Keen, Professor of Obstetrics in the Medical School at  Brunswick,
Maine.f   The woman, who was thirty-nine  years of age, had  been
in the habit of living upon rich food and drinking strong coffee, and
had suffered greatly from the disease referred to.  Under the use of
a simple farinaceous diet, and nothing but water for  her drink, pur-
sued for three years, she experienced so little pain and inconvenience
that she thought herself at times cured. -  At the end of  this  period,
at the solicitation of her friends, she lived for a few days upon strong
food,  such  as she  had not been accustomed to, and the  consequence
was a most severe  attack of pain, followed by  a foul  discharge, and,
in a few weeks, by her death.   A post-mortem examination revealed
the entire destruction of the neck of the uterus, with deep ulcers in
the body of the organ, and apertures of communication with the blad-
der and rectum.
  The late Professor  McClellan,J of Philadelphia, refers  to a case
where a genuine carcinoma of the breast was kept in check for twenty
years mainly by a course of rigid dieting.   The tumour progressed
rapidly for the first eight or ten months, until it had attained the
size of a double fist, when it began to ulcerate near  the centre, and
to discharge  ichorous  and offensive matter.   By detergent lotions,
anodynes, and emollients, with great attention  to cleanliness and the
alvine evacuations, and a diet consisting almost exclusively of milk,
bread, and vegetables, the disease was arrested, the  pain alleviated,
and the general health maintained in a good condition.
  To prevent relapse after operation for  malignant  diseases, it has
been suggested that  the patient should be restricted almost exclu-
sively to pure water.   Ponteau,§ of  Lyons, flattered  himself that he
had, by this  treatment, effected several radical cures.   His practice
consisted in  giving his patients each from five to six  pints of ice-
water in the  twenty-four hours.  At the end of three days, says he,
the appetite   usually ceases,  and the individual is  hardly  incom-
moded by the privation, living often fifty and even sixty days with-

   *  Boston Med. and Surg. Journ. vol. xli. p. 498, 1849.
   f Mussey's Report, Trans. Amer. Med. Association, vol. Hi. p. 330, 1850.
   % Principles and Practice of Surgery, p. 400, Phila. 1848.
   \ QSuvres Posthumes, t. 1, p. 96, Paris, 1783. 
IN MALIGNANT DISEASES.
41
out a particle  of  food of any kind.   Should the breath become
offensive and the  tongue coated, he  recommends the exhibition of
from  two to three drachms  of  magnesia, in divided doses, in the
morning.   At the end of two months, this rigid abstinence is aban-
doned, and the patient gradually resumes  his former mode of living,
beginning with the yolk of an egg, beaten up  in two tumblersful of
cold water, then with creams and soups, and finally with  solid  food.
Ponteau thinks that the use of ice-water is more  in  harmony with
nature than ordinary water; that it is, in short, a better tonic, and
that it  is better calculated,  so  to speak, to  deceive the appetite,
thereby rendering this feeling more endurable.
   Dr. William Lambe,* an English physician, embracing the views
of Ponteau, recommends the substitution of distilled for ice-water,
as a curative agent in this complaint;  but it does not appear that
he obtained any particular benefit from its employment.   The water
practice, as it may be  termed,  of these  writers, has  never become
popular with the profession,  and I have no  factwto offer in support
of its utility.
   Valsalva, and, subsequently, Fearon, a  surgeon of London, recom-
mended the repeated abstraction of  blood by leeches, as  a means of
curing cancer, and a  similar mode of treatment has occasionally
been  pursued to prevent relapse after operation.  It is  difficult to
perceive the modus operandi of such a remedy in such  a case, or
the principle upon which  it could afford relief.  Fearon, believing
that all cancerous  affections are of an inflammatory nature, employed
it as an ordinary antiphlogistic.
   It is hardly  necessary, in  a paper of this kind, to speak of the
various internal remedies that have been, from time to time, pro-
posed for the  cure of cancer, and for  the prevention of  its relapse
after extirpation.  Suffice it to say  that none  of them have fulfilled
the promises and  hopes that practitioners have been  led. to expect
from  their exhibition, and that there is not, in all the long and varie-
gated catalogue, a solitary one that can, in anywise or  degree, be
viewed in the light of a specific, or as a neutralizer  of the morbid
poison concerned in the production  of malignant disease, in any of
its diversified forms and  characters.   Whatever benefit may attend
their  employment flows solely  and entirely from the good effects
which they exert upon the digestive organs, and, through them, upon

  * Report  on the Effects of a Peculiar Regimen  on Scirrhous Tumours and Can-
cerous Ulcers, London, 1809. 
42           RESULTS OF SURGICAL OPERATIONS

the system at large, or, in other words, upon both solids and fluids.
If there be any remedy  calculated to prevent the formation of the
cancer-cell, or to arrest its progress after it has been developed, we
are ignorant  of it.  Human science and human  skill may destroy,
rudely and mechanically, a malignant tumour in an accessible part of
the body; but they have not yet taught us,  if, indeed, they ever can
teach us, how to  change and modify those circumstances which pre-
cede and attend its creation under the plastic powers of the capillary
vessels of the affected structures.  Possibly, the joint agency of ani-
mal chemistry,  the microscope, and  therapeutics,  may some day en-
lighten us upon a subject  which has hitherto eluded our investiga-
tions, conducted though they have been through a series of  ages, as
if to admonish  us of the imperfections of our art, the imbecility of
our nature, and the vanity of our inquiries.
  Nearly twenty years  ago, a French surgeon, M. Martinet (de la
Creuse),* thought that he  had discovered  a method by  which,  in
many cases, if not^i all, a return of the disease after ablation might
be effectually prevented.  It consists in filling up the  gap left by
the removal,  of the morbid mass  with a flap  of  sound skin, taken
from the neighbourhood, and carefully adapted, by means of stitches
and other means,  to the raw edges of the wound,  to  insure  their
speedy reunion.   The  object of the procedure  is  to  change the
functions of the parts in such a manner  as to restore their healthy
nutrition, thereby destroying  the  tendency to  cancerous  action.
When M. Martinet published his paper on the subject, in 1834,  he
had  performed this species  of anaplasty in four  instances, and  in
every one with  the most gratifying success.   One of his patients was
seen six years after the operation in perfect health;  and two others
remained without relapse  at the end of three years.  In the other
case, death occurred at the  expiration of two  years and  a half, in
consequence of an affection unconnected with cancer.   The operation
has been performed by Sedillot,y Jobert de Lambelle,  Dieffenbach,
Zeis, Baroni, Rizzoli,  and other surgeons ; but with results so unsat-
isfactory as to hold out no inducements for repeating it.  ZeisJ has
formed a  very  unfavourable  estimate of the practice, and the expe-
rience of Baroni  and Rizzoli,§ of Italy, proves that it does not exert
the slightest  influence upon  the reproduction of the disease.

           *Gaz. MeU de Paris, No. 42, 1834.
           f Annales de la Chirurgie, t. 15, p. 105, Paris, 1845.
           X Handbuch der Plastich. Chirurgie, s. 367,
           \ Bulletino delle Scienze Mediche, serie ii. vol. 7, p. 237, 
IN MALIGNANT DISEASES.
43
  My experience with this operation  is quite limited, having per-
formed it only twice.  In both cases the patient had epithelial can-
cer of the lower  eyelid, and in both  the disease returned after an
interval  of several months.  In another case, of which I  have the
particulars, the patient, a gentleman, aged about fifty, had cancer of
the lip, which, after having  been removed several times, was finally
treated by anaplasty.   For  awhile, the transplanted parts retained
their  healthy character, but at  the end  of a  few months they gra-
dually became hard and rigid, and exhibited all the evidences  of can-
cerous disease.   This patient has  just died from the  effects of his
disease.
  I  find that many  of the older surgeons,  and, indeed,  quite  a
number also  of  the modern, strongly insist upon the establishment
of an issue,  seton, or perpetual blister,  as means of preventing  a
return of the disease after extirpation.   In the time of Baron Boyer
and Benjamin Bell, the practice seems  to have been in  very common
vogue.   Monteggia, of Milan, lays much stress upon  it, as  late as
1815.*  He  says that Desault,  who neglected attention to this sub-
ject, and who permitted his patients to take  care of their health as
best they could, lost nearly every one from speedy relapse. Professor
Chelius, of Heidelberg, is  one of  the  latest writers who insist upon
the importance  of this  mode of treatment.   M. Rayer also thinks
well of it, and fancies that reproduction is less frequent after opera-
tion,  especially in cutaneous cancer, when an issue is made  in  each
corresponding extremity.
  Of the value  of this practice, which  consists in maintaining a free
discharge in  the  neighbourhood of the original disease for  several
years, or even during the remainder of the patient's life, we have no
positive information.  Those who seem to have the greatest confidence
in its efficacy have failed to adduce any facts in support of it.  Their
ideas respecting it  are evidently  of a vague and conjectural cha-
racter.  It is difficult to conceive how such an agent  could prevent
the formation of cancer-cells, and  yet  it might exercise such an in-
fluence.   I submit it to the  members of the Association, whether  it
would not be well to revive this  mode of treatment,  in connection
with  a well-regulated diet  and  strict  attention to the  bowels  and
secretions, after operation ?  The true  value of it, at all events, can
be determined only by future trials.

          *  Institution! Chirurgiche, vol. vii. p. 213, Milano, 1815. 
44
RESULTS OF SURGICAL OPERATIONS
PART II.  GENERAL  OBSERVATIONS ON CANCER, IN
  RELATION TO  THE  RESULTS OF  SURGICAL OPE-
  RATIONS.

  It will be the object of the Committee to arrange under this head
such facts and  observations as have been  contributed by different
surgeons, and gleaned from  American  and European writers.  The
information  obtained from the  two latter sources is  comparatively
meagre; but this circumstance  is to be the less  regretted, because
ample opportunity will be afforded, in the section on carcinoma of the
mammary gland, for an exhibition of the views and recommendations,
not only of our  own  surgeons,  but of the  surgeons of  different
countries, in respect  to the propriety or impropriety, utility or inu-
tility of operation for the  relief and cure of malignant diseases.
  The most  valuable information that has been furnished to the
Committee, in relation to this department of the subject, is from the
pen of Dr.  J. M. Warren, of Boston,  and from  that of Professor
Hamilton, of Buffalo.   The paper of  the former of these distin-
guished gentlemen, comprises: first,  a history of twenty cases of
cancer, as it appeared in different organs of the  body ;  secondly, a
general summary of the operations for cancer at  the Massachusetts
General  Hospital, from 1822  to  1852 ; and,  thirdly, a record of
operations for  cancer in  the  hospital  and private  practice of the
author.  The table of Professor  Hamilton gives the particulars of
fifty-nine cases of the disease, and has evidently been drawn up with
much care.  Both articles are worthy of attentive consideration and
reflection.

     § 1. FACTS AND OBSERVATIONS CONTRIBUTED BY J. MASON
                   WARREN, M.D., OF BOSTON.

  The attempt to  arrive at  the results of surgical operations in
malignant diseases is attended with many difficulties.  Most patients
thus afflicted come from a distance, to  present themselves  to a sur-
geon in the  city, either in  private or hospital practice; the operation
is performed; the patient disappears,  and is  often  completely lost
sight of.  This is true of a large majority of the  cases which occur.
The important question, therefore, seems to resolve itself into this__ 
IN MALIGNANT  DISEASES.
45
are there any cases  known of patients operated on for cancer, who
have remained well after the lapse of a number of years?   If any
such can be produced, it is certainly an important element in encou-
raging us to attack malignant growths by the knife.
   A number of  the cases,  hereafter to be given, seem to lead to the
conclusion that  a cure  by the  knife  is sometimes to  be expected;
others show that a removal of the tumouf  may be resorted to for
the purpose  of  deferring  the  evil day;  and,  finally,  a third class
exhibit  the operation simply as a palliative  to smooth the pathway
to the grave.
   The accounts  contained  in the following pages may, for the sake
of arrangement, be classified under these  heads:—
   1.  Some  operations for  the removal of cancer, from which the
patient  still survives.
   2. Others, in which the disease having been removed, has returned
after a number of years, and again been subjected to the knife with
relief.
   3.  Others, which are interesting from their peculiarity.
   4.  The statistics of cancer from  the records  of  the Massachusetts
General Hospital.  A table of these,  from the  opening of the Insti-
tution to 1850, was prepared under the direction of Dr. Parkman,
some  years since, with great care, and kindly lent  me by him.  This
has been completed  under my own  direction by Mr. Sawyer, the
present  surgical house-pupil.   A  general  summary  of these  has
been introduced in the present article.
   5.  To these have been  added some cases of my own public and
private  practice within the last  few  years, chiefly of  larger opera-
tions, no record  having been preserved of many upon the lips and
skin.   My earlier notes are also not sufficiently detailed to afford
any satisfactory results  ; and the patients, with the exception of the
cases  to be given, are mostly lost sight of.
   The  hospital  statistics  simply show the  part  most  affected by
cancer,  and the immediate  result, whether fatal or not.

   Case I. Scirrhoma of the Left  Breast.   Excision.   No Return
at the End of Twelve  Years.—1840.  Mrs. V.,  50 years  old, the
mother  of three children, has always  enjoyed good health until the
occurrence of the present disease.   Her complexion  and hair are
both light.  Early in life, she had  a milk  abscess in the left breast,
which has left a  slight induration.  She knows  of  no hereditary dis-
position to cancer. 
46           RESULTS  OF SURGICAL OPERATIONS
  About two years since, she began to have an uneasiness in the left
breast, and soon discovered a slight hardness in the glandular struc-
ture.   This  has gradually increased till it now involves the whole
breast; the nipple is retracted.   She suffers much pain, and is .very
desirous of an operation.  The  glands in the axilla seem not to be
affected.   The  breast itself is  the seat of a  large hard  tumour,
movable on the subjacent structures ;  the skin at different points is
slightly retracted and adherent to the tumour  beneath.
  The disease was  removed by two semilunar  incisions, embracing
the nipple and a portion of the adherent skin ; the breast being
large,  required quite an extensive dissection.   Dr.  J.  C.  Warren,
Dr. Cantaro, and other  gentlemen assisted at  the operation.   The
wound was brought  together by  sutures and adhesive straps, secured
by compresses and a bandage.   The subsequent prostration  was con-
siderable, but the recovery progressed  well.
  February,  1852.   I have heard from this lady,  who is now in
England.   She is in the  enjoyment of good health,  and  at  present,
so far as I can ascertain, there  are no signs of a recurrence of  the
disease.

   Case II.  Encephaloid Tumour of the Breast. Removal.  No  Re-
turn at the End of Six Years.— January, 1846.  Mrs. G., of South
Boston, 69 years of age, a small, thin woman, and the mother  of a
number of children,  has always  had  good health.   So  far as  she
knows there is no hereditary tendency to cancerous  disease.
   About  eighteen  months since a tumour  appeared in  the right
breast, and  grew with great rapidity;  so as  to involve the whole
breast in a large  tumour, of a pyramidal shape, quite tense  and
elastic, the summit  occupied by  a bright red spot, apparently on the
point of ulceration.   The tumour was quite movable  on the subjacent
parts.
   The patient, having great dread of  an ulcerated cancer, was  very
desirous to have an operation performed, and  as the tumour was on
the point of breaking through  its bounds, when severe, if not dan-
gerous hemorrhage would undoubtedly ensue,  I  consented.    The
friends, however, were first made  aware how little was to be expected
from  the removal  of a disease  which had  proceeded to  such an
advanced stage, and  also of the fact  that on the right arm there
■ was a small, movable, melanotic tumour, the size of a hazel-nut.
   The tumour  was  removed in  the ordinary way, with  as much
rapidity as  possible.  On  account of the  great vascularity of the 
IN MALIGNANT  DISEASES.
47
parts, every incision was followed by a violent gush of blood, leaving
the patient  seriously faint  at  its termination.  The edges of the
wound were approximated as nearly as the form would admit of, and
moderate compression made  by  a roller around the chest.
   On examination, the tumour was found  to  be a specimen of pure
encephaloid, in weight about three pounds.  It was shown at one of
the meetings of the Society  for Medical Improvement, and no doubt
entertained as to its character.
   The recovery of this lady  was good.   From all appearances at the
time of the operation, her chance of  living without a removal of the
disease  could  hardly have  been  estimated  beyond two or three
months; but in 1848, I saw her in good health, and am informed at
this date (Feb. 1852) that she  is still living,  and has never experi-
enced any inconvenience from  the operation or relapse  of the dis-
ease.

   Case III. Excision of the Horizontal Part of the Lower Jaw for
Malignant Disease.—May 13.   The patient was a healthy boy, fifteen
years old, with no hereditary tendency  to malignant disease, so far
as  could be ascertained.  Two years and a half since, a small red
fungous tumour made its appearance between the middle incisor teeth
of the lower jaw.   This tumour gradually increased, separating the
teeth, and  finally  involved  the whole depth  of the  bone.   At the
time of the  operation the lip was much pressed outwards, and the
cavity of the mouth so encroached upon as materially to embarrass
the speech and prevent mastication.
   The disease was removed  by making an  incision through the lip in
the median line, and extending  it  as far  as the os hyoides.   The soft
parts being dissected from  the bone, this was partly sawed through
by means of a metacarpal saw,  the second bicuspid tooth on either
side being removed.   The incision through the  bone was completed
with cutting forceps.
   Before separating the attachments between the jaw and the tongue,
a ligature was passed through the mucous membrane at the base of
that organ, in  order to prevent retraction, an accident that Dr. W.
had seen happen in an operation similar to the present, the patient
being saved from suffocation by the surgeon thrusting his finger down
the throat,  hooking up the tongue, and securing it by a ligature.
   In the present  instance there was no disposition in the tongue to
retract  but, for  the sake  of  precaution, the  ligature was passed 
48
RESULTS OF SURGICAL OPERATIONS
through the wound, and formed one of the sutures which confined
the edges of the lip when they were approximated.
   The portions of the jaw  removed show the whole bony structure
expanded and  enlarged.  On the alveolar edge  one bicuspid  tooth
remained on each side.   On the left side two incisors.   The right
incisor teeth had disappeared.   The  right  cuspidatus was found
deeply buried  in the jaw, lying diagonally across the root of the bi-
cuspid, never having come  to  the surface.  From the  expansion of
the jaw by the disease, nearly two inches existed between the bicuspid
tooth of the right side and the incisor of  the left.
   A small portion of the expanded shell of the bone being cut away
from the internal face of the jaw, exposed a fungoid mass filling the
interior.  This, on being submitted to microscopic examination, pre-
sented well-marked cancer-cells.
   The disease  was limited by the bone, the soft parts in the  vicinity
exhibiting no marks of disease.—Records Bost. Soc. Med. Improve-
ment.

   Case IV.  Scirrhus of the Left Breast.  Excision. No Return of
the Disease.—August 19, 1848.  This patient was an Irish widow, 40
years of age.  About nine months previous to her admission to the
Massachusetts  General Hospital, she suddenly experienced a sharp
darting pain in the left breast, near the nipple, and on  applying her
hand detected  a small  hard  lump, the size of a pea, which gradually
increased to  that of  a  hen's egg.   " Sharp stinging pains have trou-
bled her  for the last two  months, since the nipple began to be
retracted.   She thinks she  has nursed  her children  more from this
breast than the other."
   The breast was removed  upon the day of her admission, and in
rather more  than six weeks  she was discharged well.
   March 16, 1852.  This patient, who  is a large  powerful  person,
was seen by  me to-day.  She is now, and has been since her recovery
from the effects of the operation, in the enjoyment of perfect health.
The scar is about four inches long, quite soft, and healthy.

   Case V. Encephaloid Tumour in the Cheek. Removal. Recovery.—
A young gentleman from Halifax, aged 16 years, came  under  my
care in January, for a tumour situated in the  substance of the right
cheek.  One of  a similar nature had been removed from  the  same
situation  two years  before, but bad speedily  reappeared.  When I
saw this patient, the whole right  side of his face  looked larger than 
IN MALIGNANT  DISEASES.                49
the other, the veins were everywhere distended, and, at first sight, a
malignant disease of the antrum would have been suspected.
   On careful  examination, I discovered a lobulated tumour deeply
seated in the substance of the cheek, just below the zygomatic arch,
and apparently running up under that bone.  It was quite hard, and
moderately movable.   A large vascular polypus also  occupied  the
right nostril, and entirely obstructed the breathing through that side.
   In consultation with Dr. J. C. Warren, it was determined to remove
the tumour, which was done on  January  28, in the  presence of a
number of medical gentlemen.  Ether was exhibited by Dr. Morton,
and in  four  minutes the patient was  quite insensible.    A trans-
verse incision was then made along the lower  edge of the zygoma,
through  the skin and muscular substance, which exposed an erectile
vascular tissue, entirely enveloping the tumour, and intimately con-
nected with the surrounding parts.  In dividing  this, in order to
arrive at the body of the tumour, a hemorrhage  commenced, which
greatly obscured the dissection, and it was only by compressing  the
carotid artery that the operation  could be continued.
   The tumour was now discovered extending up under the zygomatic
arch, but only attached in that  direction by a loose cellular tissue ;
behind,  it dipped down in  the  direction of the spheno-maxillary
fissure.   It  was  finally detached from  these  different connections,
after a long dissection.  The operation  was suspended from time to
time, in  order to allow the  repetition of the ether, which was  thus
three times repeated at the request of the patient, and  after the first
time with  an  almost  instantaneous  effect.  He said subsequently
that he had  experienced no  pain, and that his impressions were of
an agreeable character.  His call for the ether, he said, was partly
for the pleasure of taking it, and  not entirely on account of the relief
it afforded him from suffering.
   In consequence of the great hemorrhage from every part of the
wound, it was finally found  necessary to stop the bleeding by com-
pression  with sponges.  No subsequent bleeding took place, and the
patient  recovered without any  bad symptoms.  One  or two weeks
elapsed, however, before the sponges could be extricated from  the
wound  so firmly were  they embraced  by the  granulations, and at
length  removal was accomplished only by tearing them away piece-
meal.  The  disease was of the encephaloid character, and entirely
surrounded by erectile tissue, the division of which  gave rise to  the
hemorrhage.   With the exception of the actual cautery, the use  of
the sponges seemed to me the only means of  stopping the flow of
       4 
50           RESULTS  OF SURGICAL OPERATIONS
blood, and from the great difficulty here encountered in the removal
of these from the wound, I  think that in a similar case I should give
the preference to the former.—Taken from the Boston Medical and
Surgical Journal, 1847.
  May, 1852. This patient I have seen within  a month, and there
bad at that time been no  recurrence of  the tumour.

  Case VI. Scirrhoma  of  the Parotid.  Removal.   Recovery.—A
large, powerful, plethoric man, 34 years of age, consulted me for a
tumour  in the right  parotid gland.  A tumour had been removed
from the same spot  twenty years ago, which shortly afterwards  re-
appeared in the form of a small, hard tubercle under the ear. For
fifteen years, it remained stationary, and then began to increase.  It
is now about the  size of  a  hen's egg, of a bluish colour, lobulated,
and having a hard base surrounded by small cysts.   The lobe of  the
ear is  pushed upward  by  the tumour, which extends inward and
apparently involves the lower half of the parotid gland.
  As the  patient was very desirous  of an operation, I  determined
on its removal.  It was a question whether it would not be advisable
to apply first a ligature to the carotid.   On examination, by a num-
ber of medical gentlemen, it was thought possible to remove  it with-
out having  recourse to  this means.  Drs. J. C. Warren,  George
Parkman, S. Parkman, Briggs, and  Mr. Slade, were  present  at  the
operation.
  Ether was given him  by Dr. Morton, who was  desirous of seeing
its effects on so powerful  a patient.  The pulse, before its exhibition,
was 90.  On commencing  the inhalation, the eyes  and  face were
much injected with  blood, but as  it  was continued he  gradually
became  pale, and in about the ordinary time was quite  insensible.
The tumour required a very slow and careful dissection;  the base of
it was found to have undergone osseous degeneration, and  pressed
upon the facial nerve as it crossed the styloid process. This was  the
cause of a paralysis of the side of the face, which was gradually
taking place, a fact I omitted to state in the history of the case.
  Towards  the middle of the operation, the patient  began to make
strong muscular exertions, indicative of returning consciousness, and
which somewhat interfered  with the dissection.  As soon as he com-
plained of pain, a second dose of ether  was administered, which took
effect speedily, and prevented him from suffering for the remainder
of the  time.  The operation occupied about half  an hour; and
although it was severe, not the slightest constitutional  trouble  fol- 
IN MALIGNANT DISEASES.               51
 lowed.   In the course of a  week, he was  able  to  return  home  to
 Maine.—Taken from the same Work.
   March,  1852.  This patient has been heard from not long since  as
 in good condition.
   These two last-recorded cases were among the earliest operations
 performed under the influence of ether.

   Case VII.  Cancer of the Eyelid.—April 25, 1839.  A healthy,
 robust-looking  sailor, 71 years old, noticed a small pimple  at the
 inner corner of the left orbit, about four years ago.   To this, others
 succeeded, which coalesced into one tumour, with a warty appearance
 on its surface, when he picked off the scab.  There have been occa-
 sionally slight  pains  in it.   At  the  present date, there is a  small
 irregular wart-like tumour on the  nasal aspect of the  left  orbit,
 covered by a thin dark-brown scab.
   On  April 28, patient being well etherized, the  tumour, with a
 sufficient portion of the healthy surrounding structures, was excised,
 and the surface touched with  potassa fusa.  Two small arteries were
 tied, and the parts brought together by four sutures.  Collodion was
 applied, forming a thin, delicate scab over  the wound.    In  about
 three weeks  he was discharged well, and remains so at this present
 time, March, 1852.

   Case  VIII.  Scirrhus  of  the Breast.—May, 1849.   Mrs. M.,
 45 years of age, applied to me for advice on account of a large hard
 tumour of  the  breast, slightly adherent to the skin, and which had
 appeared between ten and twelve years previously.  The patient was
 a powerful, fine-looking woman, the mother of  a  number of children,
 and  until the appearance of the tumour had always enjoyed perfect
 health.
   A small movable mass was first discovered implanted in the gland-
 ular part of the  breast, and  had gradually enlarged until the  whole
 of that organ had been involved.  The disease caused her much pain
 and inconvenience, though it had no decidedly bad influence upon her
 general health.   She formerly had a milk abscess in this breast.
   Under  chloric ether, the whole breast was removed, a  sufficient
portion of the integuments being saved to allow the  edges  of the
wound to be approximated.
   The disease was undoubted scirrhus.
  A day or two after the operation, a sudden hemorrhage took place
from the wound, but it was checked  before I  arrived by the simple 
52           RESULTS  OF SURGICAL OPERATIONS
application of compresses wet  with  cold water over  the  dressings.
Some suppuration ensued, union by the first  intention being pre-
vented by the coagula which had collected.   In the course of three
or four weeks, she was sufficiently well to return  home, a long  dis-
tance from Boston, the wound being then almost healed.
  During the past week (March 16, 1852), having had occasion to
operate for cancer of the breast, on a lady, a connection of  the pa-
tient, I was informed that at the present time she enjoys good health,
and has had no return of disease in the part operated on.

  Case IX. Carcinomatous Tumour of  Upper  Jaw.—April 3,
1850.  A lady, 65  years of age, had always  enjoyed  good health
until about six months since.   At this period, she observed a small
tumour  between  the middle incisor teeth  of the upper jaw, which
gradually loosened and fell out, shortly followed  by the lateral in-
cisors.
  The tumour was, at the time of her appearance, of the size of a
pigeon's egg, rather elastic, crackling, as if having a delicate shell
of bone.   The alveolar process was implicated in  the disease, which
impinged on the nasal cavities.
  The patient being brought  under the influence of ether, and the
mouth secured in  such a position, by means  of wedges  between the
teeth, that the jaw could  be  easily worked  upon, the  tumour was
removed by the knife and a  powerful cutting-forceps.  The lower
part of the left maxillary sinus was exposed  by the operation.   The
bleeding was profuse, but was  checked without having  recourse to
the actual cautery, which  had been kept  in  readiness,  in  case of
necessity.
  This patient had a good recovery, and is now (March, 1852) in
the enjoyment of  good health.   The disease removed consisted of a
shell of bone, containing in the centre a soft granular matter having
the appearance of colloid.

   Case X.  Scirrhoma of the  Left Breast.   Removal.   Reappear-
ance in the Right Breast  after  twenty years.  Removal.  No Return
since.—Mrs. B.,  50 years  of  age,  of clear complexion,  dark hair,
considerable embonpoint, good colour, and having every appearance
of fine  health, consulted me in September, 1851, for  a tumour of
the right breast.  The swelling had presented itself nine years  pre-
vious, without  any assignable  cause;  but it was  not until the last
year that it had given much trouble. 
IN MALIGNANT  DISEASES.
53
  On examination, there could be discovered a hard lump, occupy-
ing the central portion of the breast, quite firm, and having  all the
marks of scirrhus.  The axillary glands were not enlarged.
  The patient informed me that, twenty years previous, Dr. John C.
Warren removed a scirrhous tumour from the left breast, which  had
been of slow growth and was the result of a blow.
  The mammary gland and nipple were removed in the subsequent
operation  (1851), with  the  assistance  of Drs.  Minot and Abbott.
The edges of the wound were approximated by means of two or three
sutures and adhesive straps.  At the first dressing, on the third day,
the skin was found to have entirely healed by the first intention.  On
the fifth day, however, a small, painful spot was complained of by
the patient just above the  wound,  and at this point  a  collection
formed, to which it was necessary to give exit  a day or  two after.
The extremities of the wound also gave way, and discharged a bloody
serum.  The whole wound then healed regularly and kindly, and the
patient is  now (Feb. 1852) in the enjoyment of perfect health.
  This  case is interesting  from  the fact  of a removal of a scir-
rhous tumour from  the breast, and no return of  the  disease for
eleven years subsequently; a second tumour then appearing in the
opposite breast, and  nine years elapsing before it was sufficiently
troublesome to require extirpation.  Her aspect was that of a fine,
handsome woman, and wholly unlike that of the victim  of a malig-
nant disease.
  In  regard to the suppuration which  took place in the wound, I
would remark that I  have  almost  invariably observed  that where
union by the first  intention is attempted, and  succeeds, in persons
of much  adipose substance, the wound sooner or later  gives way
again from the suppuration in the subcutaneous tissue.  In thin per-
sons, a sound union may be  expected ;  in fat subjects, hardly ever,
according to my experience.

  Case XL Malignant Tumour  arising from  Periosteum of Left
Tibia.  Removal of the Limb.  Health good at the end of fifteen
months.—Dec.  1850.   A mechanic, 52 years of age, with general
good health, and no  hereditary tendency to  cancer, consulted  me,
and stated  that, about twenty-three years ago, he struck a heavy
iron hook against the middle  of the  left shin-bone, in front.  A
swelling very soon appeared, much harder than usual, not discoloured,
and very tender, which soon increased to the size of a small egg.
And thus  it remained for twenty years. 
54           RESULTS  OF SURGICAL OPERATIONS
  In the summer of 1847, the tumour was accidentally struck  by a
hammer.  At the time, the pain was excruciating, but subsided suf-
ficiently in the course of a day to allow him to attend to his business,
recurring occasionally for two or three months, mostly in the night.
At the expiration  of this period, he  perceived the tumour to  have
gradually enlarged, having in  eighteen months attained the size of an
orange, with a proportionate increase of pain.  It was very red;  at
the apex of a bright crimson, and the integument over it very thin
and tense.  The limb below was swollen and  oedematous.   Granula-
tions, bleeding at every touch, arose from a slight abrasion.  Such
was its condition when the tumour and portions of the tibia, to which
it was adherent, were removed by a surgeon.
  In  three months the wound  healed soundly, and thus  remained
about a year, when there appeared, on the outside of the  cicatrix, a
swelling of the size of a cent, which followed precisely the course of
the preceding tumour.   At the time of removal of the  limb, it had
assumed the following appearance:—
  " Six inches above the malleolus, on the outer aspect of the left tibia,
and apparently adherent to it, was a lobulated tumour,  eight inches
and three quarters in  circumference, two inches in height.  It was
somewhat constricted at its base by the integument, through which it
had extruded, as if forced up  from  beneath.   To the  inside  of  its
base was a  hard  tumour, in  size and shape like a large almond."
The apex of the large tumour had  a sloughing aspect; the integu-
ment  at the base, which was the seat of the greatest tenderness, was
reddened.
  The limb was amputated by the circular method, and upon a sec-
tion  of the tibia  the tumour was found  to have been between the
periosteum and the bone.  It was firm,  white, and fibrous, of the
size  of a walnut,  and  from  one side sprung the fungous growth
described above.

  Case XII.  Tumour of the  Right Arm, requiring Amputation at
the Shoulder-joint.—L851.  A man, tall  and thin, about 30 years of
age, had always enjoyed good health, until April, 1850, when he had
a bloody discharge from the urethra, without pain.   In June follow-
ing, there appeared under the skin of the arm, near the insertion of
the deltoid muscle, a small hard lump, which ultimately encircled the
arm, raising up the brachial vessels and nerves.   The motions of the
arm were not much affected, but for a short time previous to his ap-
plication the tumour had rapidly increased in size and in pain. 
IN MALIGNANT  DISEASES.
55
  On Feb.  15, 1851,  the  patient being etherized, an incision was
made into the tumour,  when it was unanimously pronounced  by the
medical gentlemen present to be a carcinomatous  growth.  The re-
moval of the arm at  the shoulder-joint,  as  had  been  previously
determined  upon, was  therefore performed by an anterior and pos-
terior flap.  But little blood was lost, in consequence of the scientific
compression of the subclavian artery by Dr. Williams.
  " The tumour, on dissection, presented a lardaceous appearance,
and,  under  the microscope, showed much fibrous  tissue, in which,
after much investigation, cancer-cells were distinguished."
  This patient recovered rapidly, and at the present date, February,
1852, is, I believe, in good health.

   Case XIII. Scirrhus of the Right Breast.  Excision.  Subsequent
 Tumour  in the  Thigh, of a questionable  character.—September,
1847.  Mrs.  J. W., forty-five  years of age ;  quite tall, thin, skin
somewhat dry and sallow,  chest flat, with health generally delicate,
the mother  of two  children, and no hereditary tendency to  cancer,
had a  milk  abscess in both  breasts,  leaving an induration  there.
Two years since, a tumour made its appearance  in  the inner part of
right breast, which gradually became attached to the nipple, causing
a retraction  of that organ.  At the  time I saw the patient, the
tumour was the  size of a hen's egg,  or  perhaps larger; irregular,
moderately movable, very hard.  It gave her much pain, and she
was extremely desirous of having it removed.
   From the delicate appearance  of this  patient, and the irregular
 formation of  the tumour,  I had great fears  as to  the result of the
 operation, and so stated to her friends.   As the inconvenience from
 it was so great, they determined  to have  the operation performed,
 even if it was done merely  for  the  palliative effect.   I  therefore
 went into the country, some forty miles  from Boston, for this pur-
 pose.  The whole gland,  with the nipple, and a portion of  skin, was
 removed, and the  edges  of the wound approximated with adhesive
 straps.  To my surprise and pleasure,  I heard from this patient, some
 three years after, through her physician, who said that the wound
 had healed, and  that  she enjoyed good health.   The sister of this
 patient, who  was present at  the operation, had a large tumour of
 the breast removed ten years before, which was of very rapid  growth,
 and possessed all the appearance, according to her description, of a
 fungoid disease.
    To-day, March  16, 1852, this  lady applied to me  on account of 
56           RESULTS  OF SURGICAL OPERATIONS
a hard movable tumour in the left thigh, placed over the course of
the femoral vessels, an inch  or more from Poupart's ligament.  1
asked permission to examine  her breast.   The  cicatrix, four or five
inches in length, was perfectly healthy, as were  the skin and glands
in the neighbourhood.  Her health was good, and she had been once
brought to bed of a living male child since the operation.
   As to the nature of the tumour in the thigh,  which is  without
pain, and as yet of but slight inconvenience to her, time only can
determine.   Her appearance is  quite  healthy, and  presented a
striking  contrast to what  it  was previous to the  removal  of the
cancer.
   May  4. I removed  the  above tumour, and  the patient  is now
(1853) well,  and has lately  been confined with a healthy child.

   Case XIV. Cancer of the  Breast.  Removal.   Reappearance at
the end of ten years.  Excision.—1851.  Mrs.----, sixty-four years
old, applied  to  me,  in 1841,  for a cancer of the right breast.   At
this time she was a widow, and her last child was an adult, after the
weaning  of  which the  milk had  remained  in her  breast for three
years.   The whole mammary gland had  been invaded  by scirrhous
disease,  and the skin covering it eaten off by the  applications of a
cancer doctor, who had left her in this condition  after informing her
that she was cured.
   I removed the whole breast, and the wound  healed well  by the
second intention.
   In January, 1851, I was requested to visit this patient  out  of
town, as another tumour had  made its appearance near the axilla,
and on the same  side of the  chest with  the  previous operation.   I
found the lady engaged  in her  household  affairs,  quite lively, and
not at all disposed to give  way on account  of the  reappearance  of
the disease.
   Since  my previous attendance  she had again  entered the matri-
monial state.  She had experienced no inconvenience  at the seat of
her old  disease until the last year, when a small, hard lump  had
sprung  up on  the  edge of  the  pectoral muscle,  which was now
adherent to  the skin and to the muscle.
   With the assistance of Dr. B. Brown, who accompanied  me  for
the purpose, I removed the disease, Drs. Gould and Sullivan, physi-
cians of the  place, being present.
   The husband of this lady informed me in January, 1852, that she
enjoyed perfect health, and had no return of the local affection.   He 
IN  MALIGNANT DISEASES.
57
also informed me that, previous to the last operation, she had been in
the habit of remaining constipated for five or six days,  and had some-
times gone sixteen days without an  alvine evacuation,  the food being
rejected from the stomach  once or twice in the twenty-four hours.
During the past year,  by  careful  attention to  diet  and regimen,
assisted by some saline purgatives, she  has been able  entirely to
overcome this torpidity  of the digestive function.

   Case XV. Scirrhoma of the Breast in a woman seventy-six years
old. Removal.  Return  of the Disease in the Cicatrix four years sub-
sequently.  Again removed.   Recovery.—1847.  Mrs. F----, aged
seventy-six years, of florid complexion, quite fleshy, by occupation a
nurse, entered the Massachusetts General Hospital in  October, 1847,
for a scirrhous  tumour of the right breast.  When quite a child, she
said that  a "boil"  formed  near the nipple of this breast and  dis-
charged itself, leaving a  small indurated spot under the skin.  Within
the last twenty years,  the  present disease had  been gradually in-
creasing, having commenced in the above induration,  and extending
over the whole  breast.    The  nipple  had retracted,  and a  bloody
serum issued from it.    The lancinating  pains were so severe as to
induce her application at the hospital  for relief.
   I removed the whole  breast, which was a large one, the  incision
being  over nine inches in  length,  and  she had  a good recovery,
being discharged well in about  a month.  The disease was genuine
scirrhus.
   In December, 1851,  I was requested  to  see  this patient  by Dr.
Francis Minot,  at the Hospital for Aged Females, under his charge.
She had perceived no return of  the disease, and had been quite well
until within a year, when  a small  indurated  spot appeared in the
centre of the cicatrix  made  by the former operation.  I agreed with
Dr. Minot  in the propriety of removing this  disease at  once, and,
the patient consenting, it was done by him a few days  after.   I have
since understood that  the wound healed well.

   Case XVI.  Cancer from a Blow, with Hereditary Predisposition.
—March,  1851.  Mrs.  R.,  sixty years  of age, lost her  husband a
few  months  since.   She has generally been healthy;  her father
lived to a good  age; her mother had  a cancer of the breast at the
time of Mrs.  R.'s birth, and afterwards died of cancer of the uterus.
One of her sisters had cancer of the breast.
   About six months  since, she received a violent blow on the arm 
58           RESULTS OF  SURGICAL OPERATIONS
and  chest, occasioning inability to use  the arm afterwards,  the
shoulder-joint  being quite stiff, and almost immovable.   Shortly
after the reception of the  blow she began to have pain in the right
breast, and a small, hard tumour made its  appearance there, which
slowly increased, and became the seat  of  a burning and shooting
pain.
  On examination, I found a tumour the size of an  egg, having all
the physical characters of scirrhus, to  occupy the axillary side of
the nipple, the skin at this point being drawn in and attached to it.
The stiffness of the shoulder-joint rendered it impossible to inspect
the axilla satisfactorily.   Her health had  been much impaired by
the long confinement incident to the injury of the arm, and  by a
chronic bronchial irritation,  but  the suffering from the  disease was
such that she was very anxious to have it removed.
  Previous to the operation, this  lady was placed fully under the
influence of chloric ether.   The arm then being  firmly seized, the
adhesions at the shoulder-joint were broken up, so as to impart quite
a free motion to the limb ; the injury having apparently been a  frac-
ture of  the socket, and possibly of  the  head of the humerus.   The
axilla by this  manipulation  being fully exposed, it was  found  that
the lymphatic glands in its  border were  enlarged, but  the disease
had not extended into the axillary fossa to any depth.   The entire
breast and the diseased glands were  carefully dissected  out, so that
no perceptible  disease was left.
  The morbid  tissue, examined  microscopically and otherwise, had
the distinct marks of scirrhus.
  The wound  healed well by the  first intention, and  the patient
recovered a very fair use of  the arm.  Since the operation  she has
removed from the city, and  when last  heard from  her health was
failing,  although there was no recurrence of the cancer.
  This  case presents a remarkable instance of  hereditary predispo-
sition, brought into activity at a late period of life, from an  acci-
dental cause.

  Case XVII. Testicle retained in the Groin.   Removal.   Subse-
quent Death of the Patient from Internal Disease,  apparently malig-
nant.—Feb. 1851.  The patient was a gentleman, 35 years of age.
The right  testicle had never descended into the  scrotum, but had
been retained  in the inguinal canal.  For many years  this was no
inconvenience  to him, but  lately it had been quite tender, giving him
extreme pain on the slightest pressure, which extended upwards into 
IN  MALIGNANT DISEASES.
59
the abdomen and down  the thigh.  As no treatment gave relief, I
was requested to perform the  operation of removal.
  The patient was quite delicate  in health and nervous, but with no
apparent malignant  disease  beyond what  has been stated.  After
etherization with chloric ether, the dissection was conducted with the
utmost caution, for fear of infringing on the abdominal cavity.  The
testicle  was removed with the tunica vaginalis,  which closely em-
braced and in some places strongly adhered to it.
  On cutting into  the testicle after its removal, the structure of the
organ was  found to be  completely disorganized;  the upper part  of
its body presenting the aspect of an unripe apple ; in the lower, was
a cyst filled with a jelly-like  material.   Under the microscope, some
nucleated cells were seen.
  This  gentleman recovered from the operation, but died suddenly a
year  afterwards, having suffered  for some time previously with ob-
scure symptoms of internal disease.
  In two other cases of retention of the testicle in the groin, which
I have witnessed, the organ was invaded by encephaloid disease.

   Case XVIII.  Encephaloid  Tumour of the Forearm.  Amputa-
tion.  Return in the Chest a year afterwards.—A child was brought
me in 18—, about four years old, having a large elastic tumour occu-
pying nearly two-thirds of the forearm.  The tumour was large above,
and gradually tapering  towards the wrist-joint. It was covered with
large veins,  and had a most picturesque  appearance.   The  child
seemed to be in the bloom of health ; it was quite  fat, and the cheeks
possessed a most beautiful glow.   The  tumour was congenital, but
had increased slowly since birth.   The parents were from the coun-
try, healthy, and had other children living.
  I pronounced the  disease  at once to be malignant, and  advised
immediate  amputation,  which was agreed to by the parents, and the
limb removed above the elbow.  The wound healed kindly.
  A year or two afterwards  I was requested  to attend the autopsy
of this  child.   I then learned that, till a short time before death, it
had been in good health, when suddenly it was attacked with cough,
difficulty of breathing,  and  other symptoms  of  pulmonic affection.
The  chest gradually projected,  as if yielding  to  some substance
forcing its  way out from within, and the child died as if suffocated.
  On inspection of  the contents of the thorax, the pleuritic  cavities
seemed to be filled with a mass of encephaloid disease.  The  lungs
were almost obliterated by compression against the spine. 
60          RESULTS OF SURGICAL OPERATIONS

   The amputated arm, and a most graphic drawing of the subject of
the operation, made by Mr. Johnston, are still in my possession.

   Case XIX.  Cancerous  Ulcer of the Integuments of the Chest.—
Feb. 1851. "Mr. M----, 64 years old, had a small pimple appear on
the breast, to the inside of the left nipple, a number of years since.
Within  six months this has ulcerated, and has since  resisted every
effort made to heal it.  At present, it is of the size of  a dollar, of
unhealthy aspect, with raised indurated edges.   The pain is extreme,
being hot  and lancinating in  its character.   Occasionally, there is  a
sensation of  living animals creeping  in it.  The discharge  is quite
fetid.   This gentleman is of full habit, and suffered from palpitation
and asthma."
   On account of the extreme  suffering I advised its removal, which
was very carefully done, the patient being under  the  influence of
chloric  ether.  Every  part of the disease, including a portion of
healthy skin, an inch in breadth, surrounding it, was removed.  The
wound healed well, and the patient returned home greatly  relieved
by the operation.   He was directed to use a bread  and milk  diet; to
take moderate exercise; and employ the  other means naturally sug-
gested for the preservation  of health.
  In  July  following, I regret to  say that the patient was  again
brought to  me,  having two large encephaloid movable masses on the
borders of  the axillae.   I advised against an operation, and he died
in the course of the year.

  Case XX. Cancer of the Penis.—May 12,  1847.  For the pecu-
liar hereditary predisposition, consult the Remarks on Cancer of the
Penis, in the General Summary accompanying  this paper.
  " Some months previous to the  above date, this man noticed  a
small  sore on the glans penis, which soon healed up, leaving  the pre-
puce adherent to the glans.   In the effort at withdrawal, a raw sur-
face was made on the glans, which gave origin to the present  disease.
  " On examination at  the  M. G. Hospital, the external appearance
was healthy; but on withdrawal of the  prepuce,  the whole corona
glandis  had the aspect  of  a raw granulating surface, having on the
top a  cup-like depression, three or four lines in depth, and  half an
inch in diameter.
   " On May 15, the patient  being  fully etherized, about two inches
of the penis, embracing all the disease, was  removed  by one stroke
of the amputating knife.  Three ligatures only were required." 
IN  MALIGNANT  DISEASES.                 61
  In less than a month this patient was discharged well, but died in
eight months  afterwards.—Hospital Books.
  From a review of the preceding cases, and  from the general  im-
pression of the results  of my own practice, I feel justified in drawing
the following  conclusions :—
  1. That, in a certain number of cases,  cancerous tumours, once
removed, do not again return.
  2. That in  a certain other number, the patient, after immunity for
a longer or shorter period, has a return of disease, requiring a second
operation, which sometimes proves  successful.
  3. That, in a great proportion of cases, the  disease, after removal,
returns, either  in the original wound,  in  its neighbourhood, or in
some internal organ.
  4. That, in consequence of the relief  from pain during the opera-
tion, afforded  by anaesthetic agents, and for reasons mentioned above,
it is better to  remove the tumour, provided the health be not much
impaired and  the disease yet remains local.   For,  in case of return,
it generally reappears in a milder form, and the patient is saved from
the loathsome character it assumes when allowed  to  proceed unre-
strained to a fatal termination.
 General Summary of the Operations for Cancer at the Massachusetts
   General Hospital, from its establishment, in  1822, to January,
   1852.

      Breast.     Amputation.    Removal.   Not treated.    Number.     Deaths.
W**           »         60          5         86   {£*£%*•"
_    ,  ,            _          _          0         -\a\ Amputation, 11
Encephalus,          7          5                    14   j Removed;    j|
Doubtful,            1          6          1?          8    Amputation, 1
Fungus hsematodes,   1                               1
Total,             30         71          8        109               8

   One patient had five operations for return of disease in cicatrices,
and  last wound healed.

  * One of erysipelas; the other in six months of internal disease with the wound
unhealed.
  f One of very extensive internal disease in ten days; health poor at time of opera-
tion.  Another sank in four days from the same cause.
  X Died in two months of extensive internal disease;  health poor at time of opera-
tion.
  § Died several weeks after operation;  health poor at time. 
02           RESULTS OF  SURGICAL OPERATIONS

  Five had operations on breast twice for return of disease  in  cica-
trix.
  Four of those not treated were cases where the disease  had re-
turned in cicatrices of former operations.
  Twelve were  known to have had a return of disease in the cica-
trix within a short time.
  Tongue.— Removal 11, not treated 1;  total 12.  Wound healed
9, wound unhealed 2, death 1;  total 12.   Reappearance 1.
  Lip.—Removal 9; all well.  In  one, the whole disease  was not
removed till a second operation.
  Face and Cheek.—Removal 9,  not treated 1; total 10.  Wound
healed 7, disease returned 2; total 9.
  Penis.—The case of amputation of penis for cancer, reported in
the  Surgical Records of  the Massachusetts General Hospital, vol.
xxxviii. p. 234, died eight months afterwards.  This man's father,
grandfather, and great-grandfather, all died of cancer of penis.
  There have been  eight cases of cancer of penis in the wards of
the Massachusetts General Hospital.
  Congenital phymosis existed in  two cases.
  In  one  case, phymosis  existed  at time of entrance, but  when it
commenced is not stated.
  Phymosis came on after disease commenced in one case.
  In one case, it did not exist.
  Nothing relating  to the subject  is stated in three cases.
  Of four cases of cancer of  the penis which I now call to mind, in
private practice, two had congenital  phymosis.  The fact in regard
to the other two I cannot at present remember, or discover the notes
of the cases.
  One case had the cancer limited  to the  prepuce, although  it so
nearly infringed on the  gland that  it was necessary to attack  it at
that point.
  The operation was performed in May,  1849.  I heard from the
patient one or two years  after, and there was  no return of the dis-
ease at that time.
  Amputation.—Healed 6, unknown 1; total  7.   Known  to  have
returned in the groin 2.
  Test's.—Removal 5.  One died in four weeks, of  great  internal
disease ; rest did well. 
IN  MALIGNANT DISEASES.
63
  In Groin.—Removal 2,  not treated 1;  total 3.   Wound healed
1, unhealed 1 ;*  total 2.
  Antrum.—Removal of disease 2,f both unhealed, removal of upper
jaw 3; total 5.  Well 2 ;  death 1, of erysipelas, in nine days.
  In Neck.—Removal 5.   Well 3, much relieved 1, died 1; total 5.
  In Axilla.—After removal of breasts 3.  Unknown 1, recovered
1, death, wound unhealed 1; total 3.
  Arm.—Amputations 3, did well, not treated 1; total 4.
  Leg.—Amputation of thigh  5, 2 cured, 3 died;J amputation of
leg 2, both cured;  total 7.
   On scalp.   Removed 1; well.
  From dura  mater.   Cut off; then cauterized; wound healed 1.
  Walls of abdomen above  umbilicus.   Removed 1; died in 17 days
of  great  internal disease;  operation  performed to  relieve  him of
great pain of  tumour.
   Labia and nymphse.   Removed 1;  well.
   Eye.   Organ extirpated  1;  well.
   Thigh  (Gelatiniform ?)   Dissected out 1; well.
   Of parotid.  Dissected and cauterized 1; well.
   Total number of cases, 186; of which 12 were not treated.

          * Following cancer penis.
          f In  one, the disease returned in glands of neck before healing.
          X 1 died in two weeks; 1 from cancer in groin.
I 
64            RESULTS OF  SURGICAL OPERATIONS
Recorded  Operations for Cancer in the Hospital
	No.	Sex.	Age.	Date.	Situation.	Variety.	Duration.
Private	1	F.	50	1840	Breast	Scirrhus	2 years
n	2	M.	41	1844	Right nipple	n	10 years
n	3 4	F. F.	68	1846	Right breast Jaw	Encephaloid	18 months
"	5	F.	42	a	Right breast	Scirrhus	2 years
Hospital	6	F.	28	d	a	"	5 months
"	7	F.	76	a	"	<<	20 years
Private	8	F.	45	it	it	a	1\ years
"	9	M.	50	it	Testicle	Encephaloid	
<<	10	F.	52	it	Right breast	Scirrhus	2] years
a	11	M.	64	a	Ala nasi	"	
Hospital	12	F.	23	(i	Parotid	a	8 years
<<	13	F.	39	it	Breast	a	9 months
a	14	M.	67	a	Penis	a	4 months
a	15	F.	53	a	Submaxillary gland	a	5 months
a	16	F.	36	ti	Upper jaw	Encephaloid	3 months
i(	17	F.	48	tt	Breast	Scirrhus	1\ years
«(	18	M.	38	tt	Lip	c:	2 years
n	19	F.	41	1848	Breast	tt	5 months
"	20	F.	46	it	a	Encephaloid	11 months
Private	21	F.	48	"	Left breast	Scirrhus	1 year
a	22	F.	40	it	Navel	n	1 year
a	23	F.	60	a	Integuments of chest	(<	15 years
"	24	M.	50	tt	Mouth	n	9 years
Hospital	25	F.	42	a	Left breast	tt	1 year
Private	26	F.	40	ti	Right breast	a	10 years
"	27	F.	35	it	Left breast	ii	6 months
Hospital	28	M.	54	(<	Parotid	11	9 months
Private	29	F.	33	1849	Right breast	it	2 years
"	30	M.	40	ii	Palm of hand	Fungoid	1 year
"	31	M.	7	it	Ear	a	4 months
Hospital	32	F.	52	it	Breast	Scirrhus	2 years
a	33 34	M. M.	27 54	ti	Femur Face	Encephaloid a	9 months 10 months
ii	35	M.	71	tt	Eyelid	Scirrhus	4 years
ii ii	36 37	F. F.	37 52	tt tt	Breast	a	2 years
"	38	F.	32	"	a	tt	2 years 6 months
<<	39 40	M. M.	15 52	tt	Lower jaw Tibia	Encephaloid Scirrhus	2J years 23 years 22 years
<«	41	F.	24	tt	Cicatrix on thigh	Fungoid	
Private	42	F.	50	1850	Right breast	Scirrhus	2 years Many y'rs 4 months 4 vciirs
"	43	M.	64	"	Integuments of chest	u	
n	44	F.	60	"	Border Axilla	((	
a	45	F.	56	tt	Right breast	ti	
a	46	F.	60	a	Upper jaw	Encephaloid	6 months
"	47	M.		"	Lip	Scirrhus	
Hospital	48	F.	24	it	Side	Melanosis	3 months
Private	49	F.	45	u	Right breast	Scirrhus	2 years
 
                  IN MALIGNANT DISEASES.




and Private Practice of Dr. J. Mason Warren.
65
Operation.	Immediate result.	REMARKS.
Excision	Well	Now well, 1852. (See Case I.)
a		Partially removed by a cancer doctoress, with caustic, six years previous.
a ti	u it	Now living, March, 1852.
a	ti it	Seen March 10, 1852. (See Case XIII.) Breast had always been sore after nursing.
it	tt	Seen December, 1851; well. Since had small lump
a a	tt It ii	in cicatrix. (See Case XV.) Returned in groin. Died in the course of a year.
a	ti	Ala had been destroyed; was restored from cheek by autoplasty.
Removed	a	Hereditary malignant tendency. One removal of tu-mour four years previous; another, two years pre-vious.
a	n	
Amputation	it	(See Case XX.)
Removed	a	
Extirpation	Relieved	Reappeared in a month, with wound unhealed, and large, hard glands under angle of jaw.
Excision «<	Well ti	Seen six months after; return of disease in cicatrix, ulceration, scirrhous glands in axilla; cough.
Caustic ap-	a Not relieved	Excision six months previous; return two months
plied		previous; applied too late for a second operation.
Excision	Well	Nipple retracted, and bloody discharge previous to operation.
	a a	Died six months or a year after of cancer of rectum.
n	a a	Now well, March, 1852.
ti it	a	Returned three weeks after. Died.
ti	a	Had cancer of face removed by me six years pre-vious. Died since.
ii	a	Now well, March, 1852.
ii ii	tt	Returned. Died.
ti	Much relieved	
Amputation	Relieved	Died some months after with pulmonary symptoms.
Excision	a	
a	Well a	
it	Death	From accidental erysipelas and peritonitis.
ti	Well	(See Case III.)
Amputation	a Dead	(See Case XI.) Very weak before operation; sank rapidly; no trace of malignant deposit on autopsy.
Excision	Well	Returned in axilla. Pied one year after.
i (<	a a	Encephaloid in both axillae one year after. Dead. Died one year after with typhoid symptoms.
a	a	Remained well two years. Died of internal disease.
a a	a n	Now well, 1852.
ti a	tt <<	Well until 1852; then return in axilla.
5 
66              RESULTS  OF SURGICAL  OPERATIONS
Recorded  Operations for
	No.	Sex.	Age.	Date.	Situation.	Variety.	Duration.
Private	50	M.	30	1850	Thigh	Encephaloid	2£ years
	51 52 53	M. F. F.	68 68 60	a a a	Lip Right breast Ala nasi	Scirrhus Scirrhus and encephaloid Scirrhus	1 year 1 year
a n a a a	54 55 56 57 58 59	F. M. F. M. F. M.	38 30 54 54 64 35	a 1851 a it 1"1841 2d1851 1851	Right breast Arm Left breast Ala nasi Right breast Testicle	11 Encephaloid Scirrhus 11 tt Encephaloid	1 year 6 months 14 months 14 months 1 year
a a	60 61	F. M.	49 35	<t	Left breast Ankle	Scirrhus Encephaloid	2 years 3 years
a it Hospital Private	02 63 64 65	F. F. F. M.	60 60 62 84	t< it it t<	Left breast Right breast Neck Parotid	Scirrhus a Encephaloid Fungoid	6 months 6 months 20 years 6 months
a a a a a	66 67 68 69 70	F. F. F. F. F.	60 52 50 35 50	tt tt tt t<	Right breast Left breast Right breast tt	Scirrhus tt Encephaloid Scirrhus tt	2 years 6 months 6 months 9 months 9 years
tt	71	M.	48	it	Lower lip	tt	3 years
a a a Hospital	72 73 74 75	M. M. F. F.	39 70 44 50	1852 ft tt	Back Face Right breast tt	tt ft tt tt	3 months 1 year 4 years 1 year
"	76	M.	55	tt	Parotid	k	25 years
  No. 33 had been in the hospital three months at a previous date, for disease of the
knee,  and was discharged relieved.  After the operation, some pulmonary  disease
developed itself, and when the stump had partially healed, he was transferred to the
Medical Department.  His disease was thought to have been phthisis, but no autopsy
was allowed. 
IN MALIGNANT  DISEASES.
67
Cancer— Continued.
Operation.	Immediate result.	REMARKS.
Excision	Recovered	Returned; reported amputation of thigh by quack; death on spot.
11	Well	Now well, 1852.
tt	Recovered	Operation by request of friends. Disease returned, and she died.
tt	tt	I removed cancer from her nose five years previous. Returned past year.
tt	Died	Erysipelas.
Amputation Excision	Recovered Well	Amputation at shoulder-joint. (See Case XII.)
	11 ft	First incision 1841; return 1850; second excision 1851. (See Case XIV.)
tt	Recovered	Died the year after with anomalous symptoms. (See Case XII.)
tt	Died	From erysipelas.
Amputation	Recovered	Died with pulmonary symptoms some months after.
of thigh		
Excision	Well	Milk abscess thirty years previous. Now well, 1852.
ft	Recovered	Died after of internal disease. (See Case XVI.)
tt tt	Well	Now well. 1852. Returned; bled freely from tumour before operation;
		much relieved by operation.
t<	tt	Now well, 1852.
tt	tt	Believed to be well, 1852.
tt	tf	Now well, 1852.
tt	tt	Now well, 1852.
ft	tt	Had a cancer removed from left breast twenty-five years ago. (See Case X.)
tt	Recovered	Had been three or four times operated on. Returned 1852.
tt tt	Well tt	Now well, 1852.
tt	tt tt	Had been operated on by cancer doctor during seven or eight months.
Removed	Doing well	
                                  BREAST.
                                     Scirrhus.
           Right*.......19
           Left........7
           Not given......8

           Total.......34
Deaths 8, only 3  of which were immediate.
Enceph.	Total.
1	20
2	9t
Scirrhus. Enceph.
Parotid;);
Face
Ear  .   .
Lip  .   .
Eyelid  .
Nose
Mouth  .
Upper jaw
Lower jaw
Neck
Back
Total.
  3
  2
  1
  4
  1
  2
  1
  2
  3
  1
  1
Axilla  .   .   .
Arm.....
Palm of hand    .   .
Integuments of chest 2
Penis.....1
Testicle   ....
Navel   ..... 1
Femur.....
Tibia.....1
Ankle.....
37
Scirrhus. Enceph.
 .  1   •
Total.
  1
  1
  1
  2
  1
  2
  1
  2
  1
  1
* 1 case of right breast, of scirrhous and encephaloid character, is included in the deaths.
f Disease is known to have returned in 7.
% Melanosis of the side was operated on once, and a cicatrix (enceph.). 
68          RESULTS OF SURGICAL OPERATIONS







                                  § 2. TABLE OF RESULTS OF SURGICAL



                                      By Frank H. Hamilton, M. D.,




                                                      CARCINOMA.
CARCINOMA OF
		S5,a	a					
	Original seat of	a g	a o	Sex.	Temperament.	Residence.	Occupation.	Cause.
	disease.	© a bog						
d			SO Q.					
Z		< 8	< O					
1	Mamma.	38	45	F.	Nervous.	Wayne Co., N. Y.		Been married twice, but never conceived.
2	Mamma.	40	47	F.	Nervous.	Erie Co., N.Y.		Married several years but never conceived.
3	Mamma.	41	43	F.	Lymphatic.	Monroe Co., N. Y.	Seamstress.	Married, and has children.
4	Mamma.	49	54	F.	Bilious.	Cayuga Co., N. Y.		Mother had cancer.
5	Mamma.	35 or 40	48	F.	Nervo-bilious.	Wyoming Co., N. Y.		
6	Mamma.	35	39	F.		Seneca Co., N. Y.		
7	Mamma.	45	65	F.	Sanguineous.	Windsor, Vt.		
8	Mamma.	59	61	F.		Niagara Co., N. Y.		
9	Mamma.		43	F.	Nervous.	Cayuga Co., N. Y.		
10	Mamma.	25	30	F.	Sanguineous.	New York.		Not married.
11	Mamma.	22	25	F.	Lymphatic.	Cattaraugus Co., N. Y.	^	
12	Mamma.	49	56	M.		New York.		Has unusually large breasts.
13	Testis.	31	42	M.	Nervous.	Erie Co., N.Y.	Merchant.	Mechanical injury.
14	Lymphatic gland under angle of jaw.	20	21	M.	Lymphatic.	Canada West.		
15	Lymphatic gland, or subcutaneous cellular texture in parotideal region.	19	22	F.	Lymphatic.	Erie Co., N.Y.	Housemaid.	Mechanical injury.
 
IN MALIGNANT DISEASES.
69
OPERATIONS  IN MALIGNANT DISEASES.

Professor of Surgery in the University of Buffalo.
GLANDULAR STRUCTURES.
Progress: state of part and of patient.
 Mode of    How long
operation.   remained
            cured.
How soon
returned.
How soon
  died.
Examination of product.
  Commenced on outer verge of
gland; whole breast involved and
part  of  the  pectoral  muscle
small ulcerations at two points;
health tolerable.
  Involves  two-thirds  of gland;
not ulcerated; health good.
  Involves  most of the breast;
not ulcerated; health  good.
  Involves  whole  breast;
ulcerated;  health tolerable.
  Involves  half of breast;
ulcerated.
not
not
Knife;  re-
moved  the
whole gland
and part of
pect. m.
Knife.
Knife.

Knife.

Knife.
Immedi-
 ately.
6 months
of  same
disease.
  Involves most of breast; health
poor; coughs; not ulcerated.

  Whole gland involved; not ul-
cerated ; two glands in axilla en
larged; healthy.
  Size of a hen's  egg;  nipple
much retracted;  not ulcerated.
  Half of breast involved;  not
ulcerated; health tolerable.
  Size of a small hen's egg; ir
regular;  hard;  not  ulcerated;
uear  axillary  verge  of  gland;
healthy.
  Size of a small hen's egg;  not
ulcerated.
  Size of a large nut;  one inch
below the nipple; not ulcerated.

  Testis slightly enlarged; indu-
rated; lobular; painful; not ul-
cerated; chord slightly enlarged;
health bad.
  One inch in diameter; hard;
skin adherent;  painful;  not ul-
cerated.
  Involved the whole parojtideal
region; hard; knobby; painful;
of late growing  rapidly;  health
good.
Knife.
Knife; remov-
ed  axillary
gland also.

Knife.

Knife.

Knife;  re-
moved  the
tumour only

Caustic  by
an empiric
Caustic by a
surgeon.

Knife.
Knife.


Knife.
6 years.





2 years.

2 years.




3 years.
Never
heard  of
her since.
2 years.

10 years.

8 years.
1 year.
2   years
of  same
disease.
4   years
of  same
disease
6 months,
2 years.
Immedi-
 ately.
Immediate-
ly, & 1 year
after it was
very large
6 months.
  Heteromorphous; some
portions hard and case-
ous ; other portions com-
posed of large cells, con-
taining variously-colour-
ed matter.
  Heteromorphous;  irr
regular and hard.
  Consistence of a raw
potato.
  Structure quite hard;
white   and   yellowish-
white.
  Hard;  crispy;
small cysts.
  Hard.

  Structure firm; section)
crispy.   (I am not cer-
tain that it was scirrhus,
but think it was.)
  Firm ;  cuts like car
tilage;  an  albuminous
fluid easily expressed.

Structure hard; opaque;
cut leaves a glossy sur-
face.
  Structure hard; colour
grayish-white;  glossy. 
70
RESULTS  OF SURGICAL OPERATIONS
CARCINOMA OF
	Original scr\t of disease.	•- -3 ! a g § g~		Sex.	Temperament.	Residence.	Occupation.	Cause.
c Z		II						
16	Under lip.	52	60 64 64	M.	Sanguineous.	Wyoming Co., N. Y.	Farmer.	
17	Under lip.	41	42 43	M.	Sanguineous.	Simcoe, C. W.	Farmer.	Originated from a small sore which re-mained after a fever.
18	Under lip.	40	40 56	M.	Sanguineous.	Chatauque Co., N. Y.	Farmer.	Smokes with a short pipe.
19	Under lip.	53	57 55	M.		Erie Co., N.Y.	Labourer.	
20	Under lip.	53	55 55 56	M.	Nervo-san-guineous.	Erie Co., N.Y.	Gardener.	
21	Commissure of lips.	36	38	M.	Sanguineous.	Monroe Co., N. Y.	Merchant.	
22	Side of tongue.	52	53	M.		Niagara Co., N. Y.	Labourer.	
|23	End of tongue.	44	46	F.	Nervous.	Erie Co., N.Y.		
J24	Xares.	28	52	M.	Bilious.	Erie Co., N.Y.	Farmer.	
 
IN MALIGNANT  DISEASES.
71
MUCOUS STRUCTURES.
Progress: state of part and of patient
  Began as  an ulcer,  covered
with a hard crust; the ulcer was
destroyed by caustic; four years
after this, it  involved the whole
right side of the lip, and I cut it
out and closed the  wound by
anoplasty;  it was  removed by
caustic; health generally good.
  When the  ulcer had remained
a year, caustic was applied.  The
ulcer  returned, and after  18
months  was  cut out.  Again it
returned, involving now the  sub-
maxillary gland, and after  two
years the gland also  was   cut
away ; the wound  never healed,
and the bone is at  last  diseased
also.
  Began as  a wart;  destroyed
by  actual  cautery;  returned,
and when it  had remained as an
ulcer 16 years, potential caute-
ries were applied;  the ulcer  now
spread rapidly, and I cut it out
  Began as a small hard tumour,
and when about the size  of a
hazel-nut it was cauterized;  now
it is a large,  irregular, malignant
ulcer.
  Began as  a vesicle;  when it
opened  there was left  an ulcer
with a  hard base; caustic  was
applied; it   returned,  and   the
knife was used; again it returned
and caustic was used; health not
  Began as a fissure in the skin;
became an indurated ulcer; caus-
tic was applied; it became worse;
and I removed it with a knife,
and closed it by anoplasty; health
bad.
  Began as a fissure in side of
tongue; gradually enlarged un-
til an  empiric  applied caustic;
then became much  larger;  now
ulcer is two inches in diameter;
base of edges indurated; pain
ful, &c.
  Began as a small hard lump;
when I operated it  was open,
and the ulcer about one inch in
diameter; health bad.
  Commenced as  an ulcer  in
nose; right ala destroyed,  and
inferior turbinated bone gone;
health poor.
 Mode of
operation.
Caustic.

Knife  with
 anoplasty.
Caustic.

Caustic.


Knife.


Knife.
Actual cau-
 tery.

Potential
 cautery.
Knife.
Caustic.
Caustic.
Knife.
Caustic.

Caustic.
Knife  and
 anoplasty.

Caustic.
Knife.
Knife  and
 anoplasty.
How long  How soon
remained  returned.
 cured.
5 years.
1 year.
6 months
Immedi-
 ately.
Immedi-
 ately.

1 month.
Immedi-
 ately.


1 year.


1 month.
Immedi-
 ately.
Immedi-
 ately.


2 months
Immedi-
 ately.
Immedi-
 ately.
1 year.
How soon
  died.
Examination of product.
2  years
after, of
same dis-
ease.
2  years,
of  same
disease. 
72
RESULTS  OF  SURGICAL  OPERATIONS
CARCINOMA OF MUCOUS
25
26
'27
28
29
Original seat of
   disease.
Rectum.
Rectum.
Glans penis.
Glans penis.
Glans penis.
•- "3 0 I ■Si * a < 8	a a o •? J2 < o	Sex.
33	31	M.
43	44	M.
59	60	M.
53	55	M.
44	45	M.
Temperament,
Nervous.
Nervous.
Nervous.
Nervous.
Residence.
Erie Co., N.Y
Monroe Co.,
 N. Y.
Niagara Co.,
 N. Y.
Erie Co., N.Y.
Cattaraugus
 Co., N. Y.
Occupation.
Mechanic.
Labourer.
Labourer.
Nurse.
Labourer.
Cause.
Piles.
Mechanical injury.



Congenital phymosis.
CARCINOMA OF
Skin of finger.
Skin below  outer
 angle of eyelids.

Skin of nose.
Skin of face below
 eyelid.
Skin of thumb
Skin on  back  of
 hand.
Skin over parotid
 region.

Skin of face below
 outer angle of eye.
36	49 50	M.
45	62	M.
40	45	M.
45	45	M.
75	77	M.
57	58 59 60	M. M.
50	62	M.
Nervo-san-
 guineous.
Sanguineous.


Sanguineous.


Melancholic.

Sanguineous.
Sanguineous.
Chemung Co,,
 N. Y.
Genesee Co.,
 N. Y.

Woodstock,
 Vt.

Cayuga Co.,
 N. Y.
Niagara Co.,
 N. Y.
Monroe Co.,
 N. Y.
Seneca Co.,
 N. Y.

Erie Co., N.Y.
Farmer.
Brick-
mason.
Farmer.
Mechanic.
Wart.
Hereditary.
A brother, two years
 older,  died  of  an
 ulcerated   tumour
 outside of neck.
CARCINOMA OF
38
Subcutaneous  cel-
 lular  texture  of
 face,  or lympha^
 tic glands.
42
48
49
M.
Nervous.
Erie Co., N.Y. 
IN  MALIGNANT  DISEASES.                 73
structures— Continued.
Progress: state of part and of patient.	Mode of operation.	How long remained cured.	How soon returned.	How soon died.	Examination of product.
Commenced as bleeding piles, and about four months before he was operated on it assumed a cancerous character; the caustic was applied by an empiric, and it immediately extended upward beyond the reach of the knife. Commenced as a "lump;" when operated upon it was an inch in diameter; irregular, hard, painful, ulcerated ; health bad. Bruised his penis about a year since; whole glans and a part of prepuce involved; ulcerated; health bad. Whole glans involved, and part of prepuce; health tolera-ble. Glans and part of body involv-ed ; ulcerated; very feeble.	Caustic. Knife. Knife; am-putation. Knife; am-putation. Knife; am-putation.	2 years. 1 year. 2 years. 6 months.	Immedi-ately.	4 months.	Structure hard, firm; cut surface smooth and glossy. Structure opaque and hard; also soft and gran-ular, or vegetating. Structure chiefly spon-gy and granular, being covered with minute vegetations. Structure hard; fibro-cartilaginous; warty.
TEGUMENTART STRUCTURES.					
During 14 years the wart pre-sented nothing unusual; he then tied it off, and the disease within one year involved the whole fin-ger with its bones; health good. Commenced as a " ringworm;" caustic was applied a short time since; now a large open ulcer. Began as a small crust; in five years it had destroyed half an inch of end of nose; healthy. Half an inch in diameter. Began as a wart; twice fell off and healed spontaneously; now one inch in diameter; indu-rated ulceration. When first removed was like a wart; when removed by caustic was the size of a two-shilling piece. Began as a small crust; now one inch in diameter; health good; involves lobe of ear. Began as a crust; now three inches in diameter; malar bone affected; health poor.	Ligature. Knife; am-putation. Caustic. Knife. Knife. Caustic. Ligature. Caustic. Amputation Knife and anoplasty. Knife, chi-sel, and anoplasty.	10 years. 1 year. 2 years. 2 years. 6 months.	Immedi-ately. • Immedi-ately. Immedi-ately. Immedi-ately. Immedi-ately.	He died finally of erysipe-las. 6 months.	Bone carious; soft parts heteromorphous. Structure when ampu-tation was made hard at points; also soft and pulpy.
CELLULAR TEXTURE.					
Began as a small movable tu-mour under ramus of jaw near its middle; when it had existed six years, an empiric applied a caustic ; the wound healed slow-ly, and the bone became involv-ed; health at time of second operation bad.	Caustic. Knife and saw. I re-moved more than half of inf. max.		Immedi-ately.	1 month.	Structure of bone soft, spongy, and cerebriform. Soft parts indurated and heteromorphous.
 
74
RESULTS  OF  SURGICAL OPERATIONS
CARCINOMA
		a g	a o
Original seat of		% a	"•a
t disease.		* S	*-s
		?rs	» is
o			
*l		-< 8	■< o
39	Humerus.	41	41
M.
Temperament.
Bilious.
Residence.
Erie Co., N.Y.
Occupation.
Labourer.
Cause.
40	Glands, or cellular structure of groin.	45	48	M.	Bilious.	Erie Co., N.Y.	Tavern-keeper.	Tumour.
41	Subcutaneous cel-lular texture of labia.		25	F.	Phlegmatic.	Chatauque Co., N. Y.		
42	Inner surface of uterus.	42 or 43	44	F.	Nervous.	Chatauque Co., N. Y.		
ENCEPHALOID.								
43	Mucous membrane of nares.	4	5	F.	Nervous.	Orleans Co., N. Y.		She has a scrofulous appearance.
44	Upper eyelid.	39		M.		Ohio.	Physician.	
45	Upper eyelid.	41	45	M.	Sanguineous.	Erie Co., N.Y.	Steamboat-runner.	
46	Skin over parotid region.	31	45	M.	Bilious.	Monroe Co., N. Y.		
47 48	Cellular structure under tendo-achillis. Subcutaneous cel-lular structure near ankle-joint.	55 20	56 22	M. F.	Sanguineous. Nervous.	Orleans Co., N. Y. Cayuga Co., N. Y.	Merchant.	Probably a sprain.
 
IN MALIGNANT  DISEASES.
75
OF BONE.
Progress: state of part and of patient.	Mode of operation.	How long remained cured.	How soon returned.	How soon died.	Examination of product.
Involved whole of upper arm and part of shoulder; ulcerated; bone necrosed; health bad.	Knife; am-putation at shoulder-joint.		Never healed.		Structure opaque; white; solid; hetero-morphous.
					
Tumour grew slowly at first, but rapidly during the last year; now about ten inches in diame-ter ; health impaired. Tumour large and pyriform; has a firm, elastic feel; been growing slowly. Had leucorrhoea six years; ir-regular menstruation five years; health very poor; has a large polypus projecting from vulva; pyriform, firm, elastic.	Knife. Knife. Ligature. Ligature.	1 year.	6 months. 3 months. Immedi-ately.	4 months.	Tumour weighed 2>\ pounds; structure gela-tiniform; colour various shades of green and yel-low, the green predomi-nating. Tumour weighed near two pounds ; structure fibrous and partly gela-tiniform; colour yellow-ish and greenish. First tumour weighed 1-J pounds; structure caseous, fibrous, and gelatiniform.
					
Commenced in Feb., 184-, as a polypus; four months after it was removed by the forceps; in one year it again filled the nose, and dislocated the right eye; health poor. Began as a small bright-red tumour on under side of upper Ud; cut it out four times; last time it did not heal; whole up-per lid now involved; tumour size of a hen's egg; from the first appearance of the tumour until he died was not more than three years. Large tumour, with an open bleeding surface; health poor. Tumour six or eight inches in diameter; ulcerated and bleed-ing ; health poor. In one year it had attained the size of two fists; did not ulcer-ate ; health poor. Involved most of outside of ankle-joint.	Evulsion. Knife. Knife. Knife. Knife. Knife. Ligation of common ca-rotid and caustic. Knife; am-putation. Knife.		Immedi-ately. Soon. Soon. Soon. Immedi-ately. Immedi-ately. Immedi-ately. 8 weeks in stump. Immedi-ately.	1 year. 6 months. 6 months. 5 months. 1 month.	Structure entirely he-teromorphous ; in part cerebriform, and in part firm, opaque, and occa-sionally spongy. Structure cerebriform; muscles softened and dis-organized. Structure nearly re-sembling a mammary gland, but when it re-turned it became spon-goid.
 
76
RESULTS OF SURGICAL  OPERATIONS
ENCEPHALOID—
c 2	Original seat of disease.	^8	a a ©	Sex.	Temperament.	Residence.	Occupation.	Cause.
49 50 51 52 53 54	Alveoli of superior maxilla. Alveoli of inferior maxilla. Superior maxilla, or malar bone. Probably the hu-merus near the shoulder-joint. Probably the ra-dius and ulna near the wrist. Tibia.	30 34 3 40 33 40	34 40 4 35 36 40 40	F. M. M. M. M. M.	Nervous. Bilious, Sanguineous.	Niagara Co., N. Y. Herkimer Co., N. Y. Seneca Co., N. Y. Erie Co., N.Y. Cayuga Co., N. Y. Cayuga Co., N. Y.	Farmer. Labourer. Merchant. Labourer.	Fracture.
MELANOSIS.								
55 56 57 58 59	Subcutaneous cel-lular texture and skin. Skin of shoulder. Lymphatic gland of neck. Outer margin of iris. Lymphatic glands of groin.	a o p CD a. 34 22 20	16 17 25 41 34 45 46 22 23 23	M. M. M. M. F.	Sanguineo-bilious. Phlegmatic. Sanguineous.	Erie Co., N.Y. Livingston Co., N. Y. Erie Co., N.Y. Livingston Co., N. Y.	Labourer. Merchant. Farmer. Labourer.	Complexion of family very dark; at birth he had melanotic tubercles on back of neck. Scrofulous. Mechanical injury.
 
IN  MALIGNANT  DISEASES.                77
Continued.
Progress: state of part and of patient.	Mode of operation.	How long remained cured.	How soon returned.	How soon died.	Examination of product.
Has been cut out twice; the third time it had attained the size of a hazel-nut; it was very painful and tender; I removed a large portion of sound bone; opening into the antrum. Was first cut away with a knife; returning, I removed it, when about the size of a pullet's egg, with a chisel and knife; health good. Began six months before the operation was made; then occu-pied most of the parotid region; not ulcerated; health bad. Involved most of upper arm ; open and sloughing; health bad. Began one year after a frac-ture of radius and ulna, near the seat of fracture; in two years the tumour involved most of pal-mar surface of forearm; health poor. Size of a large orange; ul-cerated; bleeding; growing ra-pidly ; bone carious.	Knife. Knife. Knife and chisel. Knife. Chisel and knife. Knife and chisel. Knife; am-putation at shoulder-joint by Dr. Winnie. Knife. Caustic. Knife. Knife; am-putation above the knee.	10 years. 2 years.	1 year. 1 year. 2 years. Immedi-ately. 1 year. 2 years.	9 weeks. 1 year.	Structure spongoid. Structure at second operation bony and spon-gy, or erectile. Structure cerebriform, cystic and bony; bone carious. Structure, the first time it was removed, was cerebriform and spongy. Structure spongoid, pulpy, and bony; mus-cles of back of leg soft; a small tumour in ham.
					
The tubercles on back of neck began to increase about a year since; I cut them out; they soon .returned, and an empiric em-ployed caustic; he died soon after. Tumour been growing several years; now size of an orange; health good. Bruised his shoulder seven years ago; always been tender; grew mostly within a month; size of a hickory-nut. First seen at junction of cor-nea with sclerotica; when size of a hazel-nut, was cut off twelve years after it commenced; in eleven years it had attained same size, and was cut off again; in one year more it was larger than before, and I extirpated the eye & lachrymal-gland; health good. It was first cut out when but two or three glands were involv-ed ; then when six or more were involved; the last operation was made since I saw her, and she died soon after.	Knife. Caustic. Knife. Knife. Knife. Knife. Knife; ex-tirpation of eye, &c. Knife. Knife. Knife.	2 years. 3 years. 4 years.	2 months. Immedi-ately. 1 year. 1 month.	6 months. 6 months	Soft; nearly gelatini-form; colour dark-brown. Structure firm, fibrous; colour mottled, black and white. Structure firm; cut smooth and glossy; co-lour dark-blue. Structure almost en-tirely a black pigment, inclosed within a thin cyst, and intercepted by a few vascular bands.
 
78
RESULTS OF SURGICAL  OPERATIONS
§ 3. FACTS AND OBSERVATIONS CONTRIBUTED BY DIFFERENT SURGEONS
      AND GLEANED FROM AMERICAN AND EUROPEAN AUTHORS.

  In a letter which I received, in March, 1852, from Professor Paul
F. Eve, of  Georgia, this gentleman informs me that he had, within
the last eighteen months, operated upon twelve cases of cancerous
tumours, in every one of which the disease had returned.   He thinks
that  surgery promises very  little in this affection.  " It might  do
more," he says,  " could  patients be brought to submit to the knife
at the earliest possible period after the disease is  known to be can-
cerous."   Dr. Eve recognizes the distinction between cancerous and
cancroid affections, and insists  upon a bread  and milk  diet after
extirpation, though none of his patients, it would seem,  have ever
fully carried it out.
  Of the various forms  of soft  cancer, Dr. Eve has never met with
an instance, whether operated on or not, in which the disease did not
end fatally, and that,  too, more speedily than in scirrhus.  His ex-
perience confirms the opinion that the  younger the patient is  the
more rapid will be the malady, and the sooner will  it occasion death.
  Dr. Eve  gives a case of cancer of the skin, for which he removed
a large portion of the right cheek, with a part of the ear; the patient
was a  man  aged seventy-five, and there was no repullulation at the
end of ten  years.
  Dr. George W. Norris, of  Philadelphia, speaks  discouragingly of
operations for the removal of malignant tumours.   In  his letter to
me, dated November, 1852, he  says: "But few, I take it, at this
day, who have had an opportunity of following their  patients, will
pretend to say that these growths do not almost invariably return."
Dr. Norris  has carefully examined the records  of  the Pennsylvania
Hospital, of which he is one of the surgeons, with regard to the sub-
ject under  consideration; but he finds  that they  furnish no useful
results of any kind.   Indeed, it would  seem that, for  many years
past, all the surgeons who have  been connected with that institution
have been so averse to the employment  of the knife  in  malignant
disease  that but very  few such  cases have  been  admitted  into  its
wards for operation.
  The testimony of Professor  Pope, of St. Louis, is  of the same
import.  " As a result," he remarks, " of my operations in  cases of
true cancer which I have been  able to follow, I can say with Broca
that " it never forgives."  In all, without exception, the disease has 
IN MALIGNANT DISEASES.
79
returned within from five weeks to twelve months after extirpation,
and every patient has,  in consequence, died sooner or later from its
effects.   The very  reverse has been the  case  with the carefully
removed cancroid affections, in whatever part of the body situated."*
  Professor Hamilton,  of Buffalo, who has paid much attention  to
the subject of malignant diseases, and whose interesting table accom-
panies this report, thinks himself authorized to  conclude, first, that
in glandular scirrhous carcinoma an operation should be  encouraged
at almost  every period prior  to the commencement of  ulceration;
the earlier, however, it  is performed, the better will be the prospect
of success.   Secondly,  that the knife should be used with reluctance
after the tumour has resumed the character of an open sore.  Thirdly,
that the whole gland should always be removed, however  limited the
disease.  Fourthly, that in tegumentary cancer, even when the ulcer-
ation  is  pretty extensive, excision,  especially with the  aid of  ana-
plasty, will frequently effect a  radical cure.  And, fifthly, that in  no
case are caustics preferable to  the knife.
  In  May, 1850,  Professor Warren, of Boston,  presented to this
Association, at their meeting in Cincinnati, an account of eight cases
of malignant disease, which  he had relieved,  if  not  permanently
cured, by excision, f  Of these cases, four  were scirrhous, and the
remainder cephalomatous.  Those belonging to the first category  all
involved the  mammary gland, and  were so well marked in  their
character, both as it respects the symptoms and the morbid  struc-
ture, as to leave no reasonable doubt in the mind of the  operator as
to  their carcinomatous  nature.  The ages of  the  patients  were,
respectively, fifty-five, fifty-four, forty, and fifty-five.
   The tumour, in the first case, had been discovered two years pre-
viously, and was, at the time of the  operation,  of the size of an egg,
very hard, and movable on the pectoral muscle, without any discolor-
ation of the skin.   The entire  breast was removed, along with the
nipple, the condition of which is not mentioned.  The  patient had
enjoyed good health up to the time  of the  operation, and had  been
the mother of a number of  children.  She finally  died, at the age
of  eighty-eight, of peripneumonia, at the end of thirty-three years
after the operation, and without any return of her disease.
   In the second case, the patient, an unmarried woman, was fifty-four
years of age,  of very large stature, athletic, and of florid complexion.

            * Letter to the Chairman of the Committee, July, 1851.
            f Transactions, vol. iii. p. 395, 1850. 
80           RESULTS OF SURGICAL OPERATIONS
The tumour is said to have been a genuine scirrhus, and was attended
with enlargement of the axillary ganglions.  She survived the ope-
ration more than twenty years, without any relapse, and  at  length
died of disease of the heart with effusion into the thorax.
  In the third case, the patient, aged forty, lived nearly nineteen
years after the extirpation, when she  died of some other malady.
The tumour, which had a scirrhous hardness, was of the  size of an
egg, painful, but not  tender, and movable  on the pectoral muscle.
The operation included only the outer half of the breast, the nipple,
with the remainder of the organ, being left intact.
  A lady, fifty-five years of age, had a tumour in  the  right breast,
about the size of an egg, hard, irregular  in form, somewhat tender,
and occasionally painful.  It had been caused, as was  supposed, by
a fall on the part the previous summer.   The tumour was  fixed, but
the gland itself was movable on the pectoral muscle.  The affected
mass, together with a portion of the mamma, was  removed with the
knife, and the woman died twenty-two years afterwards, without any
return of cancerous disease.
  In the other division, also embracing four  cases, the malady was
of a cephalomatous character, and  occupied various regions  of the
body.
  In the first case, the patient, a healthy man, aged  about thirty,
had been affected a  number  of years with a tumour, of  the  size of
an orange,  situated on the right side of the  neck  in the region of the
parotid gland.  It was of a red colour, firm and elastic to the touch,
and ulcerated on the surface.   The  wound healed in about a month,
and the patient, when last seen  by Dr. Warren,  ten years after the
operation, was perfectly well.
  A stout,  healthy man, aged thirty, of good habits, had a red,  soft,
bleeding  tumour in the left nostril, emitting a most offensive smell,
and encroaching upon the roof of the mouth and  the corresponding
nasal cavity.  It had  existed about four months, and  had been the
seat of frequent, and, at times, copious hemorrhages.  The morbid
mass was excised along with the floor of the orbit  and  the  left side
of the  palate.  The man continued well at the  end of  nine years
after the operation.   A portion of the tumour, examined after having
been sometime in alcohol,  exhibited  caudate and  fusiform  cells
similar to those observed in encephaloid.
  The  third case was that of a  boy, aged five years.   The tumour
of the form and size of a lemon, was situated in  the groin, and ex- 
IN MALIGNANT  DISEASES.
81
hibited  a  distinct cerebriform texture.   The operation  was per-
formed in 1843, and the boy was perfectly well in  1850.
  In the fourth case, the tumour involved the dura mater, and was
of well-marked encephaloid character.  At the time of the operation,
in 1847, it had burst through the skin, and was about the volume of
an  egg, of a red colour,  without  pain, and easily disposed to bleed.
A probe  penetrated  the  substance  of the tumour to the  depth of
three inches.   The hemorrhage was great,  but was suppressed  by
several  ligatures and the  actual cautery.   Several months  elapsed
before the wTound was entirely closed; but it had  remained well at
the  time  the case was reported in 1850.  The patient was a female,
twenty-two years of age.
   I have thus  given an   outline of these cases, because, first, they
have been reported by a gentleman of great experience  and intelli-
gence ;  and, secondly, because their result is in direct contradiction
to  that  of the generality of surgeons  of the present day.  The
account of them is, in many respects, defective, and hence much of
their value is  necessarily  lost.  Thus, in  at  least  two of the cases,
constituting the first group, no mention is made of the state of the
nipple or skin, and  in none  is there any satisfactory description of
the morbid structure.  The details of the other cases are given in  a
more satisfactory manner, though  not as minutely as could  have been
desired.   In one of these, a section of the tumour was  examined
microscopically,  but  as it had been  immersed for  a considerable
length of time in alcohol, no legitimate deduction can  be drawn
from the appearance of the caudate and fusiform bodies revealed by
the  instrument.   It  is to be regretted, moreover,  that  Professor
Warren   has  not informed us of the  proportion which  the above
cases bear  to his other   operations  for  the removal of malignant
diseases.
   The late Dr. Georo-e McClellan, of Philadelphia, was in the habit
of  frequently operating in carcinoma, scirrhus, or  scirrho-cancer, as
he  terms the  hard variety of this form  of  malignant disease.   He
was opposed, however, contrary to the advice of many writers, to  a
resort to the  knife  on the  first  appearance of suspicious tumours,
believing that the vascular excitement which accompanies them in
their early stage is unpropitious to a favourable result, if it does not,
indeed, always favour the speedy return of the  complaint.   He con-
sidered it of great importance, in every case, to wait until the con-
stitution  is enabled, in some  measure, to  check the progress of the
growth,  and  set up a barrier, as it were,  around its surface,  thereby
       6 
82
RESULTS OF  SURGICAL OPERATIONS
preventing its  further extension.  The older, in fact,  the tumour
is, the more favourable, he thought, the chance of a permanent cure.
   There is reason to believe that this distinguished surgeon occasion-
ally permitted  himself to operate  against his judgment,  simply to
prevent patients from falling into the hands of charlatans and cancer
doctors.   Speaking of the fact that very few patients ever remain
contented with palliative treatment, he observes: " If we do not recom-
mend the knife, or some more acceptable means of ridding them of
the existing tumour, they will be sure to go to the rude and unskilful
hands of some advertising pretender, and undergo all the hazards of
empiricism.   The moment, therefore, we find  ourselves  clear  of the
complications of engorgement and vascular irritation,  provided other
circumstances be favourable to an attempt at the radical cure, it will
generally become necessary to  decide upon the appropriate course.
In  the majority of such cases,  there can be  no question  about the
propriety of recommending the operation, which, if skilfully per-
formed, will leave the most easily cicatrizable wound,  and inflict  the
least  agony upon  the sufferer."*  Where, from timidity and  other
causes, the patient was unwilling to submit to excision, Dr. McClellan
occasionally employed caustics.   " Sometimes even large tumours,"
he says, " will slough away entire in this manner, and leave a clean,
healthy ulcer, which will  afterwards close by a sound cicatrization."!
It is to be regretted that Dr. McClellan has not favoured the profes-
sion with the results of his experience in this  mode  of  removing
cancerous growths.
  In  regard to encephaloid or medullary cancer,  Dr. McClellan
considers it as an essentially acute disease, the progress of which is
usually so rapid as to hurry the  unfortunate patient to a speedy exit
from his suffering.  It is only very rarely that the affection pursues
a chronic course, or  that its progress can be checked by remedial
measures. In the former case, all attempts at  eradicating the tumour
by an operation, while it is rapidly extending, invariably fail of accom-
plishing the desired object.  The disease will  invariably return even
before the wound left  by the knife has cicatrized, thus hastening the
fatal  issue without hardly the benefit of a reprieve.  The proper
plan, under such circumstances, is to treat the  case antiphlogistically,
in order to enable nature to set  up  a landmark against  the further
extension of the  malady.   In  this manner, the morbid action may

         * Principles and Practice of Surgery, p. 401, Phila. 1848
         f Op. cit. p. 402. 
IN MALIGNANT DISEASES.
83
sometimes be rendered dormant for a considerable length of time.
" Now, if we can seize such an emergency, and perform a justifiable
operation, it is possible, in this class of cases, as well as in those
which were  originally chronic  from the start, to  rid the patient of
his uncomfortable and dangerous companion for the remainder of his
life.   The  same rules of  procedure,  however,  should  always  be
regarded  that  we  have laid down under the head of  operations
for the  removal  of scirrhus.   We must  be  able to  extirpate the
whole of the existing disease  by  a single operation,  or it  will be
useless to make  the attempt.   The system must be free from any
such constitutional  derangement, or internal development of organic
disease, as contraindicates  an  operation upon hard cancer."*
   Dr. McClellan teaches that melanotic tumours return even more
frequently after  extirpation than  encephaloid; and he is of  opinion
also that they occur more extensively in remote parts, and secondarily
among the  internal organs.f  I  recollect a  memorable instance of
this disease, which  was under  the care of this distinguished  surgeon
while I was his  private pupil in 1827, and which strikingly illustrates
its relapsing tendency after excision.  The patient, aged about thirty-
five years, a stove-manufacturer by occupation, had a large number
of tumours, immediately  beneath the  skin, scattered all over the
abdomen, from above the ensiform cartilage to the pubes, of  a dark
bluish  colour,  movable, of a hard consistence, and of the  volume
of a pea to that of an almond.  When  first  noticed, several years
previously,  they were of  the  size and  appearance of small shot.
The general health of the man during  several months that I watched
him was excellent,  and he  was never disabled  from attending to his
business, except when laid up after operation.  The course which Dr.
McClellan pursued was to extirpate three or four of the larger tumours
at a time, and then to wait until the  resulting wounds were  healed,
when he would  resume the attack.  Thus he continued until he be-
came perfectly satisfied that further excision would be unavailing;
for as fast as he removed one  deposit another  would spring up in its
place  while, meantime, numerous  other tumours formed beneath the
surface  around.  The patient finally died from the effects  of the
disease  which no doubt had seized upon the internal organs.  The
particulars of this,  and of  several other interesting cases of melano-
sis exhibiting this tendency in the disease to return after extirpation,
are mentioned in Dr. McClellan's work on Surgery, edited by his son.
* Op. cit. pp. 411-415.                 f Op. cit. p. 420. 
84           RESULTS  OF SURGICAL OPERATIONS
versit
  My  colleague,  Dr.  Palmer, Professor of Anatomy in the Uni-
 jrsity of Louisville,  has  politely communicated to me a  case^ of
melanosis, remarkable for its latent character, and for its relapsing
tendency after operation.  A lady, aged  sixty-three, consulted him
in  the summer of 1851, in  relation  to a tumour on the top of her
head, which was giving her some pain.   It was  about the size of a
chestnut, firm in  its consistence,  of a  rounded  form, and  of a  de-
cidedly black colour.  It was first noticed, about twenty years ago,
as  a small black  spot, which'remained stationary until two  years
since, when it began to increase in size;  it had never been  painful,
and  troubled her only by being in the way of her comb in dressing
her hair.   Her health was as good as usual, she having for  years
been subject to occasional attacks of indisposition.  Professor Palmer
did not see her again until  the  following winter, when he was re-
quested to  visit her for an attack  of facial  neuralgia.  The tumour
was  now double the size as at the first examination five months ago.
The neuralgia was somewhat protracted; but as soon as  the woman
had  sufficiently recovered, the tumour  was removed with the knife.
On being submitted to the  microscope, its malignant character was
found  to be very apparent.  In a short  time, and before the wound
was  healed, a black substance, about the size of a pea, shot up among
the granulations,  and extended several lines beneath the healthy skin.
This being excised, the wound closed without any farther manifesta-
tion of disease in its immediate vicinity.   But before it had entirely
cicatrized,  other black spots began to  show themselves on different
parts of the head.  There were not less than from ten to fiftee*n,  and
they all appeared within four weeks after the operation.  At first, they
were not elevated above the skin, but  in a short time  they became
prominent; and in six weeks from their first manifestation they had
attained the size of a large pea.   The tumour  was removed in Feb-
ruary, and about the middle of April some disturbance of the general
health was first  observed.  The  woman began  to  look sallow, and
 complained of debility, loss of appetite, and indigestion.  From this
 time on she steadily declined, and in June it was evident that internal
 disease was rapidly undermining  her existence.   Severe pain  in  the
 back  and  abdomen kept her almost constantly miserable; the fre-
 quent  occurrence  of nausea  and vomiting added to her sufferings.
 Emaciation, loss  of strength, and the cancerous cachexy became very
 apparent.  About this time, Professor Palmer first noticed an unusual
 prominence of the abdomen, accompanied by an unnatural hardness
 which was not limited to any particular point, but extended over the 
IN MALIGNANT DISEASES.
85
greater portion of the walls of the cavity.  By the first of Septem-
ber,  the  emaciation was  extreme, and  the  dusky hue of the coun-
tenance was very striking.
  The tumours on the head had changed but little from the descrip-
tion  given above.  Death occurred on the 13th of September; and,
upon examination, the great omentum was found loaded with can-
cerous matter.   In several places, it was nearly as thick as a man's
hand.  There were not only numerous lumps of melanosis, but there
was  also a large quantity of encephaloid intermingled with  it.   In
fact, the  soft cancer was altogether the most  abundant, the black
deposit being scattered about in isolated patches, in the midst of the
larger mass of encephaloid.   The mesentery was found to be much
in the same condition.   In the gastro-hepatic  omentum, the mela-
nosis was more  abundant than the other form.  The liver exhibited
a very striking appearance.  The black and the white deposits were
scattered  about in patches, and intermingled with  a groundwork
having the normal colour and structure of the organ.  Near the
splenic fissure were a few rounded black masses, connected with the
gastro-splenic omentum.   The walls of the intestines were healthy.
No other parts  of the body were examined.
  The following case of apparently malignant  disease came  under
the observation of Professor Mussey, and was reported, in part, many
years  ago, in the eleventh volume of the New England Journal of
Medicine and Surgery, published at Boston.   The patient was  Dr.
G. Heaton, of Berlin, Vermont, and was fifty-one years of  age at
the time of the operation, in February, 1822.  The tumour, when
first  noticed, scarcely three months previously, was about the size of
a filbert; but, at the period referred to, it was as large as a common
fist, and had a pulpy feel at its most prominent part,  where the skin
was  also thinner and more tense than elsewhere.   As the  morbid
mass was deeply imbedded in the neck, it was deemed best to tie the
primitive carotid artery, when it was carefully removed along with
the sterno-mastoid  muscle, which was lodged  in its  substance, and
much changed in its appearance.  The wound healed kindly, and the
patient was  directed to take daily, for  some weeks,  from  fifteen to
twenty grains of the phosphate of iron.   The texture of portions of
the tumour was as perfectly encephaloid as it could possibly be.
  In a letter which I have had the honour to receive  from Professor
Mussey, dated March 22, 1853, he says: " I have this  evening  re-
ceived a note  from  Dr. John Winslow, of  Berlin,  Vermont, the
residence  of  the late Dr. Heaton, in which he assures me that that 
86
RESULTS OF  SURGICAL OPERATIONS
 gentleman never had any recurrence of the disease for which I  ope-
 rated upon him, and that he died of consumption in January, 1850,
 aged seventy-nine years."
   Sir Everard Home* informs us that, in the year  1773, it was  the
 opinion of the most eminent practitioners in London, that extirpation
 should be performed in all cases in which the surgeon was capable of
 removing the whole of the diseased structure.  This advice was given
 with  a  full knowledge  that  contamination of the system sometimes
 precedes the local disorder; yet, as the evidence of the existence of
 this contamination is not always clear, it was thought right to afford
 the patient the only chance that the power of art could offer.   " The
 want of success," continues Sir  Everard, " attending  the  greater
 part of the operations performed upon this principle, has established
 a  point which  could not  have been otherwise ascertained.   It  has
 produced complete proof that contamination does generally precede
 the absolute  alteration in structure; and, in too many instances, to
 a much greater extent than it was reasonable to  imagine.  This fact,
 which has only been  lately established, should  be made universally
 known,  as being essentially necessary to guide us  in our judgment
 respecting the propriety of performing an operation;  and I am ready
 to confess that in  all cases where the disease  has arrived  at that
 stage in which it has acquired the power of contamination, I  should
 be inclined, from the experience I have had, to  doubt  the success of
 the operation, and therefore could not venture to press it  upon  the
 mind of any patient.   But, if the  patient should desire the opera-
 tion, I would not refuse to perform it;  since, whatever my own doubts
 may be, I am not able to bring proof that  the operation will always
 be unsuccessful."
   The following  remarks  of Sir Everard are too pertinent to  the
 subject before us  to be  omitted:  " The  foregoing observations  are
 very strongly confirmed by what happens to almost every practitioner
 in surgery, who, in the early part of his practice, advises the  opera-
tion, and performs it with very sanguine hopes of success, in cases in
which, at a more advanced period of his life, from the  experience he
had acquired, he would not have proposed it.   This happened to Mr.
Hunter, and  has  happened to  myself and to those practitioners of
whose judgment I have the highest opinion."f
  Dr. William Nisbet,J  of Edinburgh, expresses himself inimical to

  * Observations on Cancer, p. 171, London, 1805.       f Op. cit. p 176
  X An Inquiry into the History, Nature, Causes, and Treatment of Cancer Edinb
1795. 
IN MALIGNANT DISEASES.
87
extirpation.  The use of the knife, he observes, is never to be trusted
as a certain resource.   " It frequently hastens on the ravages of the
malady."
   Mr. Pearson,*'on the other hand, declares that the greater number
of patients have no  return of the  disease after the  parts  affected
have been carefully dissected away.  He strongly recommends the
operation, and insists upon union by the first intention as calculated
to prevent relapse.  It may be added that this eminent surgeon had
full confidence in the  statements of Alexander Hill,  respecting the
result of his experience, referred to under the head of cancer of the
mammary gland.
   Mr. Fearon, of England, who  published the third  edition of his
work on  cancer, at London, in 1790,f strongly urges the necessity
and advantage of operation in this disease.   He declares  that it is
the only remedy,  and advises its employment  at an early  period of
the complaint,  as most likely  to  conduce  to a  favourable  issue.
Nevertheless, he does not  think  that the  operation ought  to be en-
tirely prohibited  even  when  there is  ulceration of the skin, firm
adhesion of the tumour, or extensive enlargement of the neighbouring
ganglions.   His experience seems to have been almost as favourable
as that of Mr. Nooth, alluded   to in another part of this report.
Fearon strongly insists upon healing  the wound  by  the first inten-
tion, to the neglect of which  he  ascribes  much of  Monro's bad
success.^
  The late Mr. John Abernethy,§ whose writings were formerly so
popular in the  United States,  remarks, in speaking of malignant
tumours, that,  however numerous  and  momentous the  deterring
reasons may be, yet they should not prevent  us  from operating in
many cases.   He is clearly of opinion  that the knife should be re-
sorted to whenever it  is perfectly certain that  the whole of the
morbid structures can be removed, provided always that the consti-
tution is not so disordered, or diseased, as to render such interference
nugatory.  He  directs  that great attention should be  paid to the
diagnosis  of malignant tumours,  in order  that, having ascertained
their true character, an operation may be undertaken at the earliest
possible moment, while the  complaint occupies  the smallest compass,
and there is no contamination of the system at large.   Resorted to

      * Treatise on Cancer, pp. 5-82-83.
      + A Treatise on Cancer, pp. 81-82, London, 1790.
      t See the article on Cancer of the Mammary Gland.
      J Surgical and Physiological works, vol. ii. pp. 126-27, Philad. 1825. 
88           RESULTS OF SURGICAL OPERATIONS

under these circumstances, he has known life prolonged for five, six,
or more years;  and when, after that lapse of time, the malady re-
appeared in  the cicatrice, death seemed  to  have been  the result
rather of constitutional than  of local suffering.  Mr. Abernethy
occasionally operated after ulceration had set  in, for the purpose
merely of diverting the disease, as it were, from its natural course,
and  thereby lessening  the  pain and discharge consequent  upon an
open state of the disorder.
  The views of the late Baron Boyer,* of Paris, upon this subject
are very decisive.  Regarding cancer, in common with Hippocrates,
Celsus, Monro, and  numerous  other writers,  as the product of an
internal cause, he considers it  as always liable to return after extir-
pation, whatever may be the  age of the patient, the state of the
tumour, and the condition  of  the system.   These remarks are par-
ticularly applicable to carcinoma  of the mammary glands, which he
had excised in many instances, hardly a solitary one of which escaped
relapse, although the wound almost invariably healed in a very short
time.  In a small number of  his cases death  occurred before the
completion of the process of  cicatrization, in  consequence of the
supervention of acute  disease, the symptoms of which appeared to
be influenced, in  a remarkable degree, by the state of the nervous
system.   He rejects the celebrated maxim of Celsus, that it is better
in doubtful cases to employ an uncertain remedy than to abandon the
patient to a certain death.   In commenting upon this injunction, he
very justly observes  that it would be much safer, as a general rule,
to refrain from  the  use of the knife altogether whenever  it is evi-
dent that Ave can achieve no good by it.
   Mr. Syme,f Professor of Clinical  Surgery in  the  University  of
Edinburgh, asserts that the only  proceeding that deserves at all to
be considered, as a remedy for carcinoma, is removal of the morbid
structure.  He insists upon early and complete ablation before there
is any serious implication of the lymphatic ganglions,  or contamina-
tion  of  the general system.   In speaking of  medullary  sarcoma,
the  encephaloid  disease of Laennec and  other authors,  he states
that the disease, after  excision, is very often followed by relapse.
The chance of permanent relief seems, according to this surgeon, to
be most favourable when the complaint is seated in the testicle and
bones, and most hopeless when it invades the eyeball.  In melanosis,

  * Traite des Maladies Chirurgicales, t. ii. pp. 712-715, cinq, edition, Paris, 1845.
  f Principles of Surgery, p. 73, 3d ed. Edinb. 1842. 
IN MALIGNANT DISEASES.
89
as the tendency to extension and general involvement is less marked,
the prospect of benefit  from removal is not so unfavourable as in
scirrhus and encephaloid.*
   In speaking of encephaloid, the late  Mr. Liston observes that,
if removed early, it may be arrested; but that if the operation be long
delayed a tumour of a similar nature, and more extensive, will almost
invariably be  pr.oduced.   In  several instances where he extirpated
this form of tumour both from the mamma and testis, the malady did
not return ; but in all other cases the result was unfavourable.
   Mr. Liston considers  fungus hsematodes as distinct from encepha-
loid ; and while he asserts that the latter is occasionally permanently
curable by  the knife, he maintains that the former is always repro-
duced after excision,  and that in a  more frightful  aspect, both in ex-
tent and malignity.f
   Carcinomatous  disease, according to this author, generally  returns
after ablation either in the  original integuments, in  the form of
tubercles or buds, in the  cicatrice, or in the  lymphatic ganglions;
very frequently all these parts are affected.^
   The late  Professor Samuel Cooper, of  London, whose First Lines
of Surgery were at one time so extensively employed as a text-book
in the medical schools of  this country, considers that, although
encephaloid has  a much  greater  disposition  to  relapse,  owing to
its constitutional character,  than  scirrhus, experience occasionally
brings forward a case forming an exception to this statement.  As a
proof of the truth of this remark,  he  refers to  a case   of fungus
nematodes of the testis in a  man, who recovered, and continued  well
a long time afterwards; and he adds that " we  sometimes  hear  of
 the same disease in  the eyes, breast, and limbs, being effectually ex-
tirpated  by operation, without being followed by any return of the
 complaint.   Unfortunately, he continues, the contrary more gene-
 rally happens, so that the prognosis should be  qualified by a refer-
 ence to this prominent fact."§
   Referring  to  melanotic tumours, Mr. Cooper  remarks  that the
 only chance of benefit depends upon the  early removal of the disease
 by  operation.   "An eye,   affected with  melanosis,  has been ex-
 tirpated  without any relapse for several years; and so have tumours
 of  the skin  and cellular  tissue.   Melanotic formations  under the

   * Elements of Surgery, by Gross, p. 145, Philad. 1846.
   f Op. cit. p. 152.
   \ Op. cit. p. 150.                   \ Op. cit. by Dr. Parker, vol. i. p. 460. 
90
RESULTS OF  SURGICAL OPERATIONS
tails of horses  have likewise been  frequently cut away with perfect
success.   These facts prove that melanosis in some  situations  has
more chance of effectual relief by operation than medullary cancer."*
   The late  Mr. John Burns,f Regius Professor of Surgery in  the
University of Glasgow, thinks that there can be no hesitation in the
mind of  any man, as to the propriety of urging an operation where
the tumour is recent, and unaccompanied by enlargement of  the
lymphatic ganglions.   When these bodies are diseased, he considers
that there is always much danger of relapse, the probability of which
is still  further increased by the open state of the cancer.
   Professor Burns is one  of those who  are inclined  to recommend
excision as a mere palliative measure.   Experience had taught him
that whenever we can remove all the parts apparently  contaminated,
we not merely succeed in  procuring a considerable period of health,
but, when a relapse  does  take place, death is less miserable than
where no operation is performed.
   The late  Dr. Graefe, of Berlin, affirms that he has often extir-
pated fungus hsematodes without any relapse having followed.   He
saw some of his patients in perfect health  at the end of sixteen,
eighteen, and  even twenty years.   It  is  proper  to observe, in con-
nection with the results of  the experience of this  distinguished  sur-
geon, that most of the German pathologists did not, until recently,
draw any just distinction between fungus hsematodes and encephaloid ;
or, more correctly  speaking, that  they, in common with the French,
generally employed this phrase to designate  a  class of tumours  pos-
sessing none of  the characteristic properties of malignant diseases.
The probability is that the  fortunate cases alluded to by Graefe were
nothing but  common vascular growths.
   In February, 1843, Mons. Leroy D'Etiolles,| of Paris, published
an interesting statistical account of cancer  among the inhabitants
of France, showing the frequency and  mortality  of the malady  at
different  periods of life, in both sexes,  and in different classes  of
society.  The most valuable part  of the inquiry, and that which has
a direct  bearing upon the objects  of  this  communication, was  to
ascertain the  effects  of  ablation upon the longevity  and  welfare
of the  patients  after  the operation.    Of  1172  individuals   in
whom the malady  was permitted to pursue its  own course, 18 lived

            * Op. cit. vol. i. p. 468.
            f Principles of Surgery, vol. i. p. 356, London, 1838.
            X Journal des Connaiss. Med., Paris, May, 1843. 
IN MALIGNANT DISEASES.
91
more than thirty years after the first appearance of  the  cancer;
while out  of  801, subjected  to  operation, either  by the knife  or
caustics, 4 only  attained that  period.  Of  those  who  lived from
twenty to  thirty years, 14 were  operated  on, and  34 were not ope-
rated on.  Again, of those whose lives were prolonged from  six to
twenty years, there were 88 who underwent excision, and 228 whose
tumours were not removed.   Thus, it would clearly appear, that, so
far as the prolongation of life is  concerned, the result of this in-
quiry is  opposed  to the operation.  The  statistics upon which the
above statements  are based, were furnished to Leroy by one hundred
and seventy-four surgeons, residing in different parts of France, and
many of whom, it maybe supposed, are not very accurate or competent
observers. Nevertheless, the probability is  that they are, in the main,
correct; and if this circumstance be  admitted, they exhibit operative
interference, whether by the knife or caustic, in a most unfavourable
aspect, no matter how early in the disease it  may be employed.
   Leroy himself  maintains, as a result of the facts furnished him
by his professional  brethren, the following conclusions:   1. That
extirpation does  not arrest the progress  of  cancer;  2. Extirpation
should not be adopted as a general method, except in cancer of the
lip and of the skin; and 3. Cancer  of other parts should not be in-
terfered  with, except when  hemorrhage  from  ulceration  threatens
 speedy death.*
   Mons.  Flaubert,f a  distinguished surgeon of Rouen, states  that
 most of the patients upon whom he has operated for cancer have had
 a return of the disease, either at the original site or its vicinity, or in
 some remote part.  At present, he never  resorts to the knife without
 much repugnance, and always declines  interference when the case is
 complicated with enlargement of the lymphatic ganglions, rheumatic
 pains, or  pains  in  the kidneys.  He is  convinced, notwithstanding
 some 'cases in which there was  no relapse, that the  human  species
 would  be greatly benefited if  ablation  were  almost  entirely pro-
 SCriDG(l»
    G L  Bayle, author of the celebrated Traite des Maladies Can-
 cSre'uses,  published at  Paris  in 1833, considers that, although the
 prognosis is  usually unfavourable, yet that  the number of cases of
 success on  record is  such  as  to  justify an  occasional resort to

   * New York Journ. of Medicine, vol. i. p. 420, 1843.                    #
   | Amer. Journ. Med. Sciences, n. s. vol.  vii. p. 455; also, Gazette Med. de Pans,
 March, 1843. 
92
RESULTS OF  SURGICAL OPERATIONS
the knife.   Mons.  Amussat  believes that the  operation  may occa-
sionally  save life,  though he does  not seem  to  have  any  confi-
dence in it as a general rule.  Professor Roux, while he is in favour
of extirpation as a  general proposition, admits that it is not unfre-
quently followed by relapse  and death.   He has been in the habit
of teaching  that cancerous  tumours  are sometimes removable by
local and general treatment.* Delpech was satisfied that every ope-
ration performed for the removal of  carcinoma is succeeded, sooner
or later, by a reproduction of the malady.  So thoroughly, indeed,
was he impressed with this conviction that he considered all attempts
at the destruction of the morbid  growth, whether by mechanical or
chemical means, as  a mere chimera.f
  Velpeau,| whose  writings  are  so well known in this country, lays
it down as a principle, to destroy cancerous tumours as speedily and
as effectually as possible, before  they have made any serious inroads
upon the surrounding parts, or contaminated the  constitution.   He
is inclined to regard them, primarily, as of a purely local character.
He insists, in conformity with this view, that the only hope of curing
the disease  is by its early destruction by mechanical or  chemical
means.   The longer it is permitted to remain at its original site, the
greater will be the danger that it will contaminate the  system by the
introduction of " new morbific germs."  All carcinomatous tumours
are, according to this writer,  liable to repullulate, though not in  the
same  degree, or with the same  rapidity or frequency.  The most
malignant are the melanotic, then the encephaloid, next the scirrhous,
and finally, as lowest in the scale, the  colloid.
  One of the most  recent authorities upon this subject, in France,
is Mons. Vidal (de Cassis), whose work, entitled Traite de Pathologie
Externe  et  de  Medecine  Operatoire,  is the universal text-book of
Parisian students.  In speaking of cancer, a term under which he
includes  scirrhus, encephaloid, and colloid, he declares his conviction
that it is a constitutional malady, and  therefore regards all attempts
to remove  a tumour  of this kind as  futile and irrational.  Never-
theless,  he considers a  resort to the  knife as proper in certain cir-
cumstances;  as, for example, when  the  morbid mass mechanically
impedes  the functions of an important organ, as the larynx, trachea,
or pneumogastric nerve; or where the disease increases with so much

  * Bulletin de l'Acade'mie Roy. de Mgde'cine, t. 9, 1843-44.
  f Diet, des Sciences Med. t. 3, p.  681, 1812.
  X New Elements of Operative Surgery, by Townsend & Mott, vol. Hi. pill New
York, 1847. 
IN MALIGNANT DISEASES.
93
rapidity as to threaten the speedy destruction of life.   In the latter
case, he thinks that the  malady may be deprived, at  least in some
degree, of its energy, by changing the theatre of its action, so that,
although  it may return, the patient would be likely  to live longer
than if no operation had been performed.   Furthermore, he is of
opinion that ablation would be proper where the patient suffers ex-
cessive agony, on the ground that, even if a relapse  should occur,
the second attack would be milder than the first, and thus lead to a
less cruel death.  In illustration of this view, he refers to the  case
of a woman, aged forty years, from whose  leg  he removed a very
painful cancer, consequent, apparently, upon a former application of
the actual cautery, and who had survived two years with hardly  any
suffering,  although the disease had shown itself on  the head soon
after the  operation.*
   Another very respectable  French  authority  is Mons.  Ne'laton,!
whose  work  is also extensively used as a text-book,  and which ex-
hibits  an  excellent outline of  the  existing state  of surgery as it  is
taught and practised in Paris.  This writer thinks that no  operation
should be performed:  first, when  there is no certainty that we  can
remove every portion of the  affected parts; secondly, when the tu-
mour coexists with cancer in some internal and inacessible viscus;
thirdly, when there is full evidence of the  presence of the carcino-
matous cachexy; fourthly, when the malady affects certain organs,
as, for instance, the eye, experience having shown that, in this case,
it always returns soon after extirpation, and progresses with fright-
ful rapidity; and, fifthly, when the disease  is extremely chronic in
its march, as occasionally happens in old  persons.  After stating
that some surgeons also  oppose  the operation  when there is more
than one  tumour, when it has followed the use of the knife, when  it
has advanced with great rapidity, or, finally, when it is ulcerated, he
remarks that, although these  are certainly unfavourable cases, yet he
does not consider them as positive contraindications.  " We see, for
example," says  he, "permanent  cures after a  second, and even a
third operation  ; nay, we may add," he continues, " that even if we
were  sure that  there would be a relapse, we ought  still to operate
in certain cases; for this relapse may be delayed for a  longer or
shorter time, and when it does show itself, we may by a second  ope-
ration postpone the fatal issue.

        *  Op.  cit. t. i. p. 494, Troisieme  edition, Paris, 1851.
        f Elemensde Pathologie Chirurgicale, t. i. p. 370,  Paris,  1844. 
94
RESULTS OF  SURGICAL OPERATIONS
  Mr. Skey,* one of the surgeons of St. Bartholomew's Hospital,
London, seems to think the removal of malignant tumours, in  many
cases, a matter of serious doubt, on account  of the  liability of the
disease  to  return.   He  asserts that  operations for malignant affec-
tions of the female breast become less and less frequent in proportion
to the age and experience of the surgeon.   He rejects, as unfit for
such a  proceeding, all  cases of tumours marked by rapid growth,
large size, and indefinite outline, by considerable enlargement of the
axillary ganglions, by the presence of ulcerative action, and by con-
stitutional disturbance.
  Professor Pirrie,f of  Aberdeen, Scotland, regards  removal by ex-
cision as the advisable proceeding.  The operation should be resorted
to early, before the establishment of lymphatic  invasion, and should
be performed effectually, the surrounding tissues being raised to  a con-
siderable extent along with the tumour.  Operative interference, after
the occurrence of lymphatic disease, would only bring discredit upon
surgery by subjecting the patient to useless suffering, followed by a
return of the  tumour, and probably, also, by a more  rapidly fatal
termination of the case.
  Mr. Fergusson,! Professor of Surgery in King's College, London,
the latest English authority, while  he admits with every unprejudiced
observer that the removal of malignant growths by the knife is very
liable to be followed by relapse, nevertheless enjoins that an opera-
tion should always be resorted to,  provided all the morbid structure
can be embraced in our  incisions.  Excision, in his judgment, affords
the only chance of security, and hence he  considers  it the duty of
the practitioner to urge the patient to submit to it.  The operation
should be performed as early as possible, before the complaint  has
made much progress. When the skin is seriously involved, when the
lymphatic  ganglions are  numerously or considerably enlarged, and
when the general health is much impaired, or the system  tainted  by
the morbid action, it would be unwise to interfered
  The following are the conclusions at which Dr. Walshe has arrived,
after a careful study of  the whole subject of cancer, in his celebrated
work:||  "Here, then, may be  closed the inquiry into the efficacy of
excision  as a  therapeutical measure.  From  the facts, fio-ures and

    * Operative Surgery, p. 388, Phila. 1851.
    f Principles and Practice of Surgery, by Dr. Sargent,  p. 771, Phila. 1852.
    X System of  Practical Surgery, p. 140, Phila. 1853.
    \ Op. cit., p. 186.
    || On the Nature and Treatment of Cancer, p. 244, London, 1846. 
IN MALIGNANT DISEASES.                95
inferences now brought forward, the conclusion is inevitable and im-
perative, that extirpation  of cancerous  growths with the knife can
neither be regarded as a means of curing cancer, nor of  prolonging
the existence of persons afflicted with the disease.  The accumulated
experience of intervening ages, dispassionately scrutinized and fairly
interpreted, pronounces the very verdict that was upwards  of two
thousand years ago rendered  by Hippocrates  in  his  memorable
aphorism.   The lapse of centuries of  civilization has done no more,
in respect to the question of operation, than to furnish elements for
demonstrating what the observant genius of one man had, in an era
of comparative barbarism, so acutely divined!"
   Professor Bennett* believes that excision ought to  be had recourse
to, both as a  curative and as a palliative remedy.   " Undoubtedly,
the  earlier it is performed the more it is likely to be attended with
permanently good results.   But even in advanced cases it should be
tried with hopes of success; and so long as it continues to return in
the same place, the excision should be repeated."  ..." The
 practical rule, then, which pathology and experience  unite in  causing
 us to adopt, seems to be this: that so long as a cancer remains fixed
 in a part which is capable of being removed,  and the strength of the
patient  is not much reduced,  so long  is the surgeon warranted to
 interfere.   If this applies to cancerous, it does so with tenfold force
 to cancroid growths, which everything that we know warrants  us in
 asserting  are  much less fatal and malignant."  We have  already
 seen that, in the opinion of Dr. Bennett, cancerous tumours are for
 some  time purely local in their character.
   Mons. Broca, the latest systematic writer  on cancer, believes that
 excision should always be resorted to, both in primary and relapsed
 cancer, provided the general  system remains  free from  infection.
 The sources of this infection will thus be removed, and its occurrence
 delayed.f   This advice is  given by Mons. Broca,  in despite, as it
 were, of the discouraging results of operation, of which no one seems
 to be' more fully aware than himself.  In his  Thesis, published a few
 years ago, of which an abstract is to be found in the St. Louis Me-
 dical and Surgical Journal,  for September, 1851, from the pen of
 Professor Pope, he announces his conviction, first, that, in genuine
 cancer  the disease always  returns, sooner  or later, after  extirpa-
 tion,  either in or around the cicatrice, in the corresponding  lympha-

   * On Cancerous and Cancroid Growths, p. 245, Edinb. 1849
   t British and Foreign Med.-Chir. Review, for  January, 1853,  p. 116; Newlork ed. 
96
RESULTS OF SURGICAL  OPERATIONS
tic ganglions, or, more rarely, in some other part of the body;  and,
secondly, that the relapsed tumour always progresses, both locally
and generally, more rapidly than the original one.   After a second
operation, repullulation is more prompt than after  a first.   He has
never known reproduction  to be postponed longer than two years,
while in the great majority  of  instances he  has found it to happen
in six months.
PART  III. —OF CANCER  OF PARTICULAR ORGANS,
  IN RELATION  TO  THE  RESULTS  OF  SURGICAL
  OPERATIONS.

  In drawing up this report, I have deemed it my duty to speak of
carcinoma as it  occurs  in particular parts  of the body, with a view
of exhibiting the results of operations  performed for its relief or
permanent cure.   Such a course was absolutely indispensable, as it
would have  been impossible without it to determine whether  the  dis-
ease is more amenable to this mode of treatment in some structures,
or situations, than  in others.   A careful perusal  of  this portion of
the labours of the  Committee will show that there is no difference in
this respect, but that true cancer is equally incurable, no matter how
early or how thoroughly it may be removed, in whatever organ or
tissue it  is located.  It will  be perceived  that a very large part of
this branch of the  subject is devoted to  carcinoma of the breast;  a
circumstance which will not appear singular, when it is remembered
that this  organ, from  its prominent position, and  its remarkable
liability to this disease,  has been, from time immemorial, the seat of
constant operation.

              SECT. I.—CANCER OF THE BREAST.

   Cancer of this organ occurs  chiefly under  two varieties of form,
the scirrhous and encephaloid.  Of these, the first is doubtless by far
the more frequent, especially as a primary affection.   Colloid  and
melanosis are exceedingly uncommon, and have hardly received  any
notice as distinct maladies of this  gland.

§ 1. VIEWS OF HIPPOCRATES, CELSUS, AND OTHER ANCIENT AUTHORS.

   It is not a little surprising that  the excision of cancerous  tumours
should have been interdicted  by Hippocrates, who  practised at an 
IN  MALIGNANT DISEASES.
97
 age and in a country in which complaints of this kind might natu-
 rally be supposed  to have  been uncommon.  The fact that  he did
 clearly shows that his knowledge of the disease  and of  the results
 of operative interference must have been  much more extensive than
 surgeons seem willing to admit.   The precise language  of Hippo-
 crates, as rendered by Dr. Francis Adams, in his  learned edition  of
 the genuine work  of the Father of Medicine, is  as follows :  " It is
 better not  to apply any treatment in cases  of occult cancer;  for if
 treated, the patients die quickly;  but if not treated, they hold out
 for a long time."*
   In the time of Celsus, practitioners were in the habit of removing
 cancerous tumours, especially those of the mamma and face, with the
 knife, the actual cautery, and escharotics.   None of these methods,
 however, as this writer  explicitly declares, were  attended with any
 benefit,  since  the  disease  nearly always  returned,  even after the
 formation of a cicatrice, and  conducted the patient  more rapidly  to
 a fatal issue than if no operation had been performed.   Notwith-
 standing this, Celsus was in favour of a resort to these measures  in
 the incipient stage of the malady; but, in its more  aggravated  forms,
 he thought the physician should content  himself  with soothing and
 palliative remedies.f
   Leonidas,| of Alexandria, was  the first  to recommend  indiscri-
 minate amputation  of the breast for  cancer.  The only case which,
 in his judgment, contra-indicates the operation, is where the whole
 organ is involved in  the disease, and where it is  so firmly adherent
 to the walls of the chest as to render it impossible to detach it with-
 out compromising  the life  of the  patient.  We have no  account  of
 the results of his experience; nor,  indeed, does it seem certain that
 he himself ever performed the operation which  he so strongly re-
 commends.
   Antyllus,§it would seem, once amputated a cancerous breast; but,
 although  the woman  recovered from  the immediate effects of the
 operation, she was attacked some time after with  carcinoma  in the
 other gland, which caused her death.

  * The Genuine Works of Hippocrates, translated from the Greek, by Francis Adams,
LL. D. vol. ii. 758, London, 1842.
  f Lib. 5, cap. 18, \ 2, p. 186 ; Sprengel, Histoire de la Medecine, t. vii. p. 422, Paris,
1832.  It is due to this writer to state that I have derived much aid from him, in re-
spect to the authorities cited in this part of my report.
  X iEtius, Tetrab. c. 45, p. 611;  c.  50, p.  618.  Sprengel, op. cit. p. 423.
  I Rhazes, Continens. lib. 13, c. 2, fol. 257.
       7 
98            RESULTS  OF SURGICAL  OPERATIONS

  Paul,* of iEgineta, was fully aware of the repullulating tendency
of cancer of the breast.   He expresses himself an  advocate of the
operation of  Galen,  and also recommends a method of his  own,
which, however, he rarely, if ever, practised in genuine  cancer of
this organ.
  Rhazes,f who, as has  been already stated, flourished in the latter
part of the ninth and the commencement  of  the  tenth  centuries,
thought that,  although cancer might occasionally, in its incipiency,
yield to internal remedies, yet that when it had advanced to ulcera-
tion the only means  of safety for the patient was  extirpation.  He
advised that the operation should  be  executed with the greatest pos-
sible care;  and, in order to guard against relapse, he  enjoined that
the knife should be carried  not  only through the  healthy textures,
but that it should  include all the enlarged veins in the neighbour-
hood.  The mamma having  been thus removed, the  surface of the
wound was  immediately burnt with  the redhot iron, when means
were resorted to for promoting the speedy detachment of the slough.
Rhazes does not inform his readers  of the  result  of this  kind of
practice.
  Albucasis,J the countryman of Rhazes, and who practised a hun-
dred years later than that distinguished  physician, doubted the pro-
priety  of operative interference in all cancerous tumours, asserting
that he never  cured or saw cured, a solitary instance of that impla-
cable malady by this or any other remedy.
  Abu'l Kasem,§ another Arabian, recommends a resort to the knife,
but explicitly states  that he  has  no  confidence in it, because he had
never  seen a  single  cure achieved by it, either in his own hands  or
in those of other practitioners.
  From the twelfth until near the middle of the eighteenth century,
little success seems to have  attended the removal of the  mammary
gland  on account  of carcinomatous  disease.  If a  permanent cure
occasionally followed, it was  regarded as an  exception to a general
law, which deterred many practitioners from intermeddling with this
complaint in any of its stages.  A relapse was  but  too sure to take
place,  whatever method  of  procedure was  employed, whether the
knife,  the ligature, the actual cautery, or escharotics.

     * Opera, lib. 6, cap. 45, p. 192.
     f Continent lib. 13, cap. 2, fol. 256.  Sprengel, op. cit. t. viii. p.  425.
     X Miller's Principles of Surgery, p. 29, Am. ed. 1845.
     \ Chirurgia, lib. 1, \ 50, p. 96; Sprengel, op cit. t. vii. p. 427.
f 
IN MALIGNANT DISEASES.
99
  John Tagault,*  who published a  treatise on  surgery about the
middle  of  the  sixteenth century, absolutely repudiates all operative
interference in cancer of the mamma.   Amatus Lusitanusf was also
averse both to  extirpation and the actual cautery.  He cites a great
number of cases where, by palliative treatment, the cancers were
kept in check  for  a long time, but which became speedily covered
with frightful ulcers, and  occasioned  death when they were treated
with the hot iron,  or caustic applications.  Ehrenfried Hagedorne|
saw several cases of relapse after operation; a  circumstance which
made such an  impression  upon his contemporaries  that many were
deterred from having recourse to it.  De la Motte§ had no confidence
in the operation.   Triller, || Professor of Surgery at Wittenberg, was
in  favour  of interfering at a very early  stage of the disease; but
discouraged the operation in cases of long-standing, being satisfied,
from ample experience, that  relapse under  such circumstances is
inevitable.
   Fabricius Hildanus,T[ on the other hand, was in favour of ampu-
tation, and he refers to several examples in which the procedure was
crowned with complete  success.  Nicholas  Tulp** shows that extir-
pation is the only means by which the patient can be saved.  Francis
Ellain  and Denys  Gue'rin, two writers on  cancer at the commence-
ment of the  seventeenth century,  declare that the  malady is in-
curable by any other  remedy than  excision.   J.  B. Denis  affirms
that  he saw a  surgeon, named Raulin, amputate several cancerous
breasts with  success.  D. Van  de   Sterre and John Muys relate
several successful examples.   Dionis  expresses himself favourable to
the operation;  and Ledran thinks  that it  affords the only resource
in  this disease.  In 1739, C. N. le Catff wrote a prize memoir in
which he  attempted to  establish, as  a general  proposition, the pro-
priety of amputating in all cases of  cancer, even when  apparently
of  the most desperate character.  He considered that the bad success
of  the  operation  was  dependent, mainly, upon a  want of care in
approximating  the edges  of the wound, thus favouring suppuration

         * Instit. Chirurg. lib. 1, cap. 15, 1555.
         f Curat. Med. cent. i. p. 62—cent. iii. p. 245.
         t Obs. et Hist. Med. Pract. Frankof et  Lips. 1698
         g Traite Complete de Chirurgie, t. i. ob. 112, p. 5.
         || De Nociva Cancri Inveter. Extirp.  Viteb. 1752.
         ff Cent. 1, obs. 89, p. 69; Sprengel, op.  cit. t. viii. p. 436.
         ** Obs. Med. lib. 1, cap. 33, p. 97.
         |f Haller,  Biblioth.  Chir. vol. ii. p. 176. 
100          RESULTS OF  SURGICAL OPERATIONS
instead of union by the first intention.  He also insisted upon the
importance of saving as much integument as possible.  Repullulation
was  to  be apprehended  only when the cancer adhered to  the ster-
num.  John  Louis  Petit*  was  in the habit of operating for cancer
of the mammary gland;  and he was  one  of the first, if, indeed, not
the first, to include in his incisions all enlarged axillary ganglions ;
a practice adopted by all modern surgeons.

      § 2. VIEWS OF AMERICAN AUTHORS AND  PRACTITIONERS.

  The late Professor Dorsey,f  of Philadelphia, who wrote the first
systematic work on  surgery that this country has produced, expresses
himself as an advocate for an early resort to the knife, before the
cancerous poison is absolutely formed,  and the neighbouring  parts
are contaminated.   The operation is most likely to eventuate favour-
ably when the  morbid growth  can be completely  eradicated;  when
the malady arises from accident, and not spontaneously; when  the
general health is good; and when cancer is tardy in its progress, and
does not involve the circumjacent structures.
  Professor Gibson says:  " Under  favourable circumstances,  the
operation  very frequently succeeds  perfectly, and  the patient never
has the slightest return of  the complaint; it must not be concealed,
however, that it often returns very  unexpectedly, and advances with
wonderful rapidity,  and in a way plainly to show that the knife has
not only not eradicated the disease, but hastened its  progress."   He
avers, positively, that whenever  the lymphatic ganglions are much
enlarged,  and of stony hardness, the operation never succeeds.^
  Dr. Gibson does not" agree with some modern surgeons that extir-
pation of the mamma is never  successful under any circumstances.
He refers, as a proof  of  the truth of  his statement, to the case of a
lady in Maryland, upon whom he had operated thirty years ago, and
who  was still alive at the time he wrote  his work.  He has also met
with several  other  examples, where ten, fifteen,  and twenty years
have elapsed  without a return of the malady. §
  The late Dr. Physick, it would  seem, occasionally extirpated  the
mammary gland when there was enlargement of the lymphatic gan-
glions, although he was opposed to the practice as a general rule.
     * Traite" des Maladies Chirurgicales, t. i. p. 223.
     f Elements of Surgery, vol. i. p. 393, 1813.
     X Institutes of Surgery, vol. i. p. 176, seventh edition, Phila. 1845.
     \ Op. cit. vol. i. p. 177. 
IN MALIGNANT DISEASES.
101
In some of his cases, the malady returned after the operation;  but
in a  few, he had the satisfaction  to  believe that life had  been pro-
longed by it, his  patients  having remained free from all disease for
several  years.*  In one of his cases the tumour was ulcerated,  and
yet the woman enjoyed  an immunity from the disease for nine years
after its extirpation.   At the end of this time, several hard  lumps
showed themselves  at  the cicatrice, and  death occurred  in  a  few
months after, f
   The views of the late Dr. Joseph Parrish,  of Philadelphia, upon
this  subject, are entitled to great respect, both  because he was a close
observer, and  because he  was in the habit  of recording what he
saw  with scrupulous fidelity.   After considerable experience and ob-
servation, he confesses that he was much discouraged as to the final
success of  all operations  in  cancerous  diseases of ,the  mammary
gland. |  He  never resorted to  the  knife  in any case  where the
affection had invaded the axillary ganglions  or fixed itself upon the
parts beneath the breast,  except at the  particular request  of the
patient, with  a full explanation  of his conviction of the probable
inefficiency of the remedy.  When  the organ  alone was involved, he
advised the operation, but even here he regarded it as affording only
a doubtful prospect of escape;  he was never disappointed in finding
the  disease  return, and  finally  carrying off his patient.  He re-
peatedly saw the cicatrice removed  by a second operation; but never
with final success.   He  considered  cancer to be essentially a  consti-
tutional affection, and  doubted  whether it  ever arose purely from
external injury.   He  had never witnessed any cases of  cure from
low  diet, depletion, and an avoidance of  exciting causes.  He had
been led to believe that many  of  the cases of  cure reported in medi-
cal journals had  not  been examples of cancerous, but of ordinary
maladies, rendered suspicious  by their  alarming appearance, or by
the obstinacy with which they resisted various therapeutic remedies.
   There was one  form of  cancerous disease  of the breast which Dr.
Parrish regarded as particularly malignant, and  to which, it would
seem, his attention was first directed by the late Dr. Physick.  This
was  a peculiar granulated condition  of the  surface of the affected
gland, imparting to the finger the sensation  as if it were  filled  with
small shot.  Dr. Physick considered this as the most dangerous form

  * Dorsey's Elements of Surgery, vol. i. p. 393, Phila.  1813.
  f Mussey, Transactions Amer. Med. Association, vol. iii. p. 336.
  % North American  Med. and Surg. Journ. vol.  vi. p. 300, Philadelphia, 1828. 
102          RESULTS OF  SURGICAL OPERATIONS
of the malady, in which he  never knew an operation to prove ulti-
mately successful.   The  experience  of Dr. Parrish fully  coincided
with that of the "Father of American  Surgery."  "I once ope-
rated," says he, "upon such a case  in the Pennsylvania  Hospital.
The disease was confined altogether  to the breast,  and,  as far as
could be  ascertained by the sight or the touch, was entirely removed.
The wound healed kindly, and for a short time the patient appeared
comfortable;  but in a few months the  complaint returned, and soon
terminated fatally."*
  The late Dr. J. Kearney Rodgers, of New York, one  of the ablest
and most enlightened  surgeons our country has ever produced, and
who died only as it were yesterday, was induced, at an early period
of his professional career, both from personal examination  and  from
correspondence and intercourse with many of the most distinguished
men at home and abroad,  to take strong and decided ground against
operative interference in  cases of cancer of the mamma.   In a con-
versation which I had with  him  on  the subject,  only a few months
before his lamented death, he expressed himself in the  most  unqua-
lified  manner, declaring  that  his experience, even under  the  most
propitious circumstances,  was adverse  to ablation, and  condemning,
in the most pointed manner, the reckless conduct of the so-called
knives-men, both in this country and  in Europe.   His conviction,
based  upon an extensive and well-observed practice of  thirty years,
was clear and positive that excision was useless even as a  means of
prolonging life, while, as a curative agent, it  had utterly failed in
every instance that  had fallen under his eye.   He had his doubts
even whether, in genuine  cancer of this organ, the operation was ever
justifiable in any case.
  The results  of  the operations of Professor B.  W. Dudley, of
Lexington, have been eminently discouraging;  for  it would  seem
that he never removed a scirrhous breast without a recurrence of the
disease.  He states that he has witnessed the  healing of a carcino-
matous ulcer, as large as a  man's hand, within a month, under the
influence of a fervid imagination, when all  of  a sudden, just as the
last point was expected to cicatrize, the force of the imagination gave
way, the ulcer reopened,  and the patient died  in  a few weeks.   He
has checked the morbid action for several years by severe abstinence
but has never seen it cured, f

           *  Op. cit. vol. vi. p. 295.
           ■j- Transactions Amer. Med. Association, vol. iii. p. 331. 
IN  MALIGNANT DISEASES.
103
  The late Dr. Twitchell, of New Hampshire, extirpated the mam-
mary gland in a good many instances, on  account of scirrhous dis-
ease.   In almost all there was a  reproduction of malignant action
in some other part of the  system, carrying off the patient.   In a
few cases only, where a most rigid diet, excluding oils and sugar, was
perseveringly observed, was there an immunity from relapse.*
  Dr. W. L.  Atlee, of Philadelphia, has  met with  an instance  in
which he operated in  March, 1843,  and  where there was no re-
turn  of  the  malady at the  end of seven years.  The patient was
eighty-six  years of age;  the  skin  was corrugated, ulcerated, and
attached to the tumour; the axillary ganglions were  unaffected, and
the whole breast was removed.f
  Dr. Usher Parsons, of Providence, R. L, in his learned Boylston
Prize Dissertation on Cancer of the Breast, published at Boston  in
1839, has this language:  " To the patient, then, and to himself, the
surgeon  must hold up the following propositions: 1. That the extir-
pation of a  scirrhous tumour, whether  indolent or painful, large or
small, recent or of long-standing, is no  positive security against  its
reappearance,  and that the same is  true in respect  to  cancerous
degenerations of other tumours and  ulcers.  2. That the danger of a
return is greatly increased when the disease has  been of long-stand-
ing, or of rapid progress in its  development, or, if ulcerated, and
especially if it  has affected the  axillary glands, or  adheres to the
subjacent muscles.  3. That there is but little hope of preventing a
return by operating after the constitution exhibits marks of cancer-
ous cachexy."
  Dr. Parsons says that, in this country,  so far as  his  inquiries
had extended  at  the  time he published his essay, the  proportion of
relapses, after operation, was at least two-thirds.  Three years pre-
viously,  he had stated the proportion of final cures at more than one-
half.   Farther  examination, however, had satisfied him that this es-
timate was too high.  It is to  be regretted that  Dr. Parsons has not
accompanied his paper with  the data upon which he has founded this
singularly exaggerated statement respecting an  operation, the final
issue of which  is so generally unfavourable as to have become a re-
proach to the profession.
  Professor Knight, of New-Haven,! has frequently extirpated the
breast for scirrhous disease.  He thinks himself authorized to state

  * Mussey's Report, Trans. American Med. Association, vol. Hi. p. 334.
  t Op. cit. vol. iii. p. 334.                       X  Op. cit. vol. iii. p. 335. 
104          RESULTS OF  SURGICAL OPERATIONS
that, in all cases in which there was lymphatic invasion, or enlarge-
ment of the axillary ganglions, there was a recurrence of the carcino-
matous action, either in some  of the neighbouring  structures or in
some internal organ, thereby destroying life.   In those cases, on the
contrary,  in which the malady was of comparatively slow growth,
and without any involvement  of the circumjacent  parts,  the opera-
tion  was  occasionally successful,  in  the proportion, probably, of
about one in four or five.  In  a few instances, a tumour appeared in
the cicatrice, or in its immediate  neighbourhood, and was removed
with a favourable result.   In one case he extirpated four such lumps,
which had appeared successively at intervals  of  about a  year,  from
an old lady, who survived the second operation eighteen years, and
died at the age of ninety-five.
  Dr. Knight  is of opinion that in many of the cases of scirrhus of
the mamma, in which the malady returned after  extirpation, the
operation had  the effect of prolonging life for a  considerable period.
This is  not true, however, of  soft cancer, the encephaloid, cerebri-
form, or fungoid disease of authors, in which there was invariably a
relapse, augmenting the patient's suffering, and causing death sooner
than if no operation had been performed.
  The experience of Professor Mussey, in cancerous diseases of the
mammary gland, is  anything  but  encouraging as it respects opera-
tion ;  for in all his cases, except two, in which he has been able to
ascertain the  results, there  has been a return of the morbid action
in some part of the system within  four years, and in most of them
within twelve  months.  In  the two exceptional cases, there was no
involvement of the nipple,  areola, skin, or  axillary ganglions;  and
the tumour, although hard,  sometimes  painful,  and  occupying the
whole organ, was not adherent at its base.  One of the patients was
forty years of  age,  and was  entirely well ten years  after the opera-
tion ;  the  other was under thirty, and  in good health eight years
after.  Dr. Mussey observes, with  reference  to  these cases,  that if
they were  malignant, they were obviously not the most  so.  " He
has but little  to boast of from his own  experience  in this opera-
tion."*
  Professor Eve, of the  Nashville University, informs me that the
results of his operations upon  cancerous breasts have been eminently
unfavourable;  for he does not know of a  solitary instance in which
the malady did  not return  and terminate fatally, where  the  diag-
nosis was unequivocal.
                         *  Op. cit.  p. 333. 
IN MALIGNANT  DISEASES.
105
  Professor Pope, of St. Louis, in a letter to me, dated July, 1851,
states that he  had removed the  female breast in a dozen instances
for supposed malignant affections.   Some of his patients had died,
some had had no return of the malady, and of the rest he was unable
to learn the history after they had left his hands.
  Dr. Traill Green,  of Easton, Pennsylvania, formerly Professor of
Chemistry at Washington College, in that State, has communicated
to me the following  interesting case of cancer of  the mamma.  The
patient  was fifty  years  of  age, of sanguine temperament, and still
menstruating;  the tumour, for which no cause could be assigned, was
five  inches in length by four in breadth, irregular on the surface, free
from adhesions to the subjacent parts, and unaccompanied with re-
traction  of the nipple, disease of the axillary ganglions, or change
of structure in the  skin.  The  general health  was perfect.  The
whole gland was removed with the knife, together with  an  elliptical
portion of the skin, about an inch and a  half in width.  Four months
afterwards, the cancer returned in the integuments and was again
excised.   Another relapse took place in two months;  and,  notwith-
standing  the  use  of constitutional remedies and the application of
caustics to the parts, the woman  expired twenty-two months and a
half after  the first operation.  The morbid products were examined
by the microscope, and exhibited the characteristic  cancer-structure.
   Dr. Green  states that he  once knew a female who had a small
tumour in one of  her mammae, which another practitioner, who  saw
the  case with him, supposed to be carcinomatous, but which gradually
disappeared without any particular medication.   The  individual  is
now living and in good health, beyond the menstrual period. In an-
other case, a surgeon endeavoured to persuade a woman to permit him
to remove her breast, which he represented to be  in a cancerous con-
dition.   She declined the operation, and is now in  excellent health,
the  gland secreting good milk for an infant born  not long ago.  Had
these cases been  subjected to operation, they would have been pro-
nounced as successful cures.
   In November, 1843, Dr.  Joshua B. Flint, of Louisville, removed a
fungous tumour from the  right breast of a lady, aged twenty-five
years; the  disease having existed  several months, and exhibited all
the  characteristic features of that heteroclite deposit.  In conse-
quence of a puncture made  a week previously, a growth, half as large
as a fist, protruded  through  the skin, and was the seat of frequent
and exh'austing  hemorrhages, threatening  a  rapidly fatal termi-
nation.   The integuments  being so extensively  involved, a portion 
106          RESULTS OF SURGICAL OPERATIONS
of the  wound  had  to  heal by  granulations, which several times
assumed a suspicious  appearance; but  the parts finally cicatrized
under the use of tonics and simple dressings, and a complete recovery
followed, the patient remaining well in April, 1850, and having, in the
mean time, given birth to two healthy children.  It is stated that the
morbid  product exhibited, under the microscope, the characteristic
structure of fungus haematodes.*
  The annexed tables have been obligingly prepared for  me  by my
friend  Dr. J.  Rowan Pirtle,  of this   city.   The  first  comprises
eighteen cases  of  scirrhus,  collected  from various sources, and  the
second twenty-nine  cases, transferred from M. Canquoin's Treatise
on Cancer.
* Transactions of the Amer. Med. Association, vol. iii. p. 337, 1850. 
I.  Table of Malignant Diseases of the Mammary Gland.
6	0> bit	■6 •— c3	Tempera-	Resi-	Cause.	Dura-	Progress and symptoms.	Mode of	Result.	Structure.	Surgeon.	Page and	Date.		"When last
2 1	< 50	1	ment.	dence.		tion.		treatment.				name of work			seen.
				London	Spon-	4 y'rs	Slow; axillary glands en-	Excision			Morgan	187 Lancet	April,	1826	
					taneous		larged.								
2	44	1		"	"	l y'r	Slow; not painful.	a		Scirrhous	B. Cooper	91 "		1826	
3	60	1		tt	Blow	ly'r	Painful; ulcerated.	a		a	Wardrop	622 "	Jan.	1827	3d day.
4	40	1		!<		2 y'rs	Slow; painful; nipple re-tracted; axilla involved.	ti		"	B. Cooper	831 '<	Sept.	1827	
5	49	1		a		7 y'rs	Slow; ulcerated and painful.	it		a	Wardrop	286 "	June,	1827	4th day.
0'f>8		1	Sanguine	tt	Blow	2 y'rs	Painful and slow; ulcerated.	a		Hard	Morgan	800 "	Aug.	1827	10th day.
7-36		1	Nervo-	a		1 y'r	Slow and very painful; ax-	it	Apparent	Scirrhous	L. Ray	282 "	Sept.	1828	2 months.
			bilious.				illa involved.		cure						
8	45	1	Sanguine	a		18mo's	Painful.	"				735 "	July,	1828	
9	45			a		2 y'rs		a		a		765 "	Sept.	1829	
in	42	1	Nervo-bilious.	a		5 mo's	Painful.	"		n	Morgan	573 "	July,	1827	
11	47	1		tt		8 mo's	Nipple retracted; painful.	a	Fatal	"	Scott	30 "	March,	1832	Died3dd'y.
12i42		1		it		2 y'rs	Slow; axilla involved.	a		a	Stanley	2S6 "	June,	1832	
13	45	1	Nervous	it		9 mo's	Painful; rapid; axilla in-volved. Slow; rapid; latterly pain-	a		"	Lawrence	144 "	Dec.	1832	
14	47	1	Nervous	it	Blow	2 yr's		a	Apparent	it	Lynn	421 «	Sept.	1833	2 weeks.
							ful ; nipple retracted.		cure						
15	44	1		a		2 yr's	Slow; ulcerated.	ti	"	a	Martinet	154 "	March,	1830	2 years.
K	29	1		a	Blow	3 yr's	Slow; hectic fever.	"		it	Martinet	155 "			3 years.
17	43			a		1 y'r	Slow.	a		tt	Lloyd	794 "	Sept.	1835	
18	41	1	Nervous	"		1 y'r	Slow.	a		a	Luke	374 "		1849	
 
			II. Table		of Malignant h		incases of the Mammary Gland.—Cases transla			ted from	the work of I	)r. A. Canquoin, (		)1 I'ans.	
		'u u 1	a '■n	Tempera-ment.	Resi-dence.	Cause.	Dura-tion.	Progress and symptoms.	Mode of treatment.	Result.	Structure.	Page and name of work.	Surgeon.	Date. When last seen.	
1	58			Sanguine.	Paris.	Spontaneous	1 year	Gradual; lauciuatiug pains.	Vienna paste and chloride of zinc.	Cure	Scirrhous; fibro-car-tilaginous; size of	123 Traitemenl du Cancer.	Canquoin	S'ov. 1837	March, 1838.
											the feet.	par le Doeteur Canquoin. 126 Cam|Uoiu.			
2	M	1			France.		3 year;?	Reappeared after excision and	Vienna paste and chloride	«	Five inches in di-		"	Tune, 1835	)ied in
								ulcerated; system involved.	of nine; tonics internally.		ameter.				lext y'r.
3 4( 4J3l		]			Paris.	Blow	1 year	Slow.	Internal; local.	Resolution	Hard ; size of egg.	211 "	"	March, 1835-1 year.	
			1			Blow	1J year	Slow and painful.	Internal, saturnine, cata-plasms, &c. Emollient and other appli-	"	Size of turkey egg.	212 "		Oct. 1835	
5 36		1			«	Spontaneous	2£ y'rs	Gradual and painful; axilla		tt	Both tumours size	213 "	"	Sept. 1837	
								tender; both mainmoe.	cations & tonics internally.		of a goose egg.				
638			1	Nervo-san-	"	Blow	8 years	Painful; system undermined.	Internal and emollient.	Partial re-solution.		219 "		Sept. 1837	
7 30		1		gutne.	a		2 years	Painful; axilla involved as well as mammae of both sides.		Resolution	Firm.	220 "	u	Nov. 1837	4 mo's.
8'41		1			a		9 years	Painful; slow.	Cataplasms, &c.	"	Very hard.	222 "	"	Oct. 1836	"> mo's.
9J50		1			"		13 y'rs	Both mammae.	Customary treatment.	"	Fibrocartilaginous; scirrhous.	225 "		Feb. 1837	
10 4:'		1			ii		3 years	No pain; slow.	Customary treatment.	"	Hard; size of walnut	226 "	u	July, 1837 April, 1837	
1131		1		Xervo-san-	"		6 mo's	Painful; axilla tender.	Customary treatment.	"	Size of pigeon's egg.	227			
1 12 Oil		1		guine. Lymphatieo-	ti		1 year	Slow; lancinating pain.	Vienna paste.	Failure	Scirrhous.	229	"	August, 1837	
1 13 71		1		sauguiue. Sanguine.	tt		6 years	Slow; painful; ulcerated.	Chloride of zinc.	Cure	Scirrhous.	234 "	a	March, 1836	2 years.
14 27			1	Lymphatic.	"		4 years	Ulcerated; painful; axilla in-volved.	Vienna paste and chloride of zinc.	"	Scirrhous.	236 "		July, 1S36	1£ year.
15 63		1		Sanguine.	"		3 years	Painful; ulcerated; strength depreciated.	Cataplasms, Vienna paste. chlor. /.inc. nitrate silver.	"	Hard.	238 "		Oct. 1836	16 mo's.
1042		1		Ililioso-san-guine.	"	Blow	3 years	Painful; ulcerated; adherent to pectoral muscle.	Vienna paste, chloride of zinc, &c; internals.	"	Scirrhous.	241 "		March, 1837 Feb. 1S3S	1 year.
17 48		1			ii		3 years	Painful; axilla involved in	Vienna paste and internal	a	Encysted, scirrhous	244 "	"		
								swelling.	treatment.		and encephaloid.			Jan. 1837	
18 41		1		Lymphatico-	"	Blow	10 mo's	Painful, and skin inflamed.	Vienna paste, &o.	tt	Very hard.	246 "			
19 >s		1		sanguiue.	tt		6 years	Ulcerated; axillary ganglia	Caustic.	a		248 "	tt	Dec. 1836	1 year.
20 3'J		1		Xervo-san-LCiiini1.	France.		1 years	swollen. Reappeared after amputation byLisfrane; adhering.	Vienna paste, chloride of zinc, &c.	Partial cure	Scirrhous.	251 "	a	March, 1837 May. 1837	
21 36		1		.Sanguine.	Paris.		2 years	Ulcerated; painful.	Cataplasms, &c.	Resolution	Scirrhous.	255 "			
22 4.".		1			France.			Reappeared after amputation:	Emollient, &c.	Failure	Scirrhous.	258 "		March, 1836	
1 23 45		1			u			ulcerated; painful.	Vienna paste.	«		259 "	a	March, 1S3!	
24 50		1		Sanguine.	Paris.		10 yr's	Slow; axilla swollen; adherent to muscle; painful.	Vienna paste.	Cure	Fibro-cartilaginous.	260 "		Sept. 1837	1 year.
25 60		1		■*\-iir.ruine.	«			Ulcerated; painful.	Vienna paste.	Par'l cure	Scirrhous.	203 "	"	August, 1836 April, 1S30	
•v. :.i		1		Sanguine.	a				Caustic.	"	Fibro-cartilaginous	269 "			
27 4S		1			a		2 years	Adherent and ulcerated.	Vienna paste.	Cure		271 "	"	April, 1x3	
28 56 29		1			ti		2 years	Reappeared after excision.	Vienna paste; chlor. zinc.	"	Scirrhous.	272 "	"	June, 183	' I year.
		1			"			Reappeared after excision.	Vienna paste.		Scirrhous.			1835 3 years.	
 
IN MALIGNANT DISEASES.
109
       § 3. VIEWS OF ENGLISH AUTHORS AND PRACTITIONERS.

  Dr.  Alexander  Monro,* Primus, Professor of Anatomy in the
University of Edinburgh, in 1742, asked the question, -whether can-
cerous tumours, when they cannot be resolved, ought to be extirpated,
or be  treated merely palliatively?  The subject had evidently en-
gaged  much  of his attention, and he was anxious to obtain from his
professional brethren, in every part of Europe, an expression of their
views respecting it.  At the time  he wrote, he had witnessed nearly
sixty cases of cancer, in which the tumour had  been removed with
the knife, and of these  four only remained free from  the  disease at
the  end of two years.   Of these " lucky people," as he quaintly
styles them, three  had occult cancer of the breast, and the  other had
an ulcerated  cancer of the lip.  He observed that, when the disease
relapsed, it was more violent and more rapid in its progress than it
was  in those  persons who had  not undergone any operation.   It  is
proper  to  state that, in Dr. Monro's time, the wound made in the
operation,  instead of being united by the first intention, was allowed
to heal, if it would heal  at  all, by the granulating process.  It would
seem that this gentleman was in the habit, in his own cases, of direct-
ing that the sore, when reduced to the size of the palm of  the hand,
should be kept open as  an issue during the remainder of lifelf
   Dr.  Monro was  of the opinion  that it was proper to operate in
ulcerated cancer,  attended with rapid wasting of the patient, as the
only means of prolonging life.  He  also thought that  in  an occult
cancer, occurring  in a  young healthy person, as a consequence of a
bruise or hurt, the hope of preventing a relapse should induce the
surgeon to have recourse to the knife.
   Diametrically opposed to the  result  of the  experience  of the
Edinburo-h  professor is the  observation of the  late  Mr.  James
Hill an eminent  surgeon of Dumfries, Scotland, and the author of
a  work  entitled  Cases  in Surgery,  particularly of  Cancers, and
Disorders of the Head from External Violence,  issued at Edinburgh
in 1772.  At the time of the publication of this work, Mr. Hill had
extirpated, from different  parts of the  body, not less  than  eighty-
eio-ht cancers, all of which, except four, were in an ulcerated condi-
tion.  He regarded the disease, in every instance, as of  a genuine

     * Edinburgh Medical Essays, vol. v. p. 421, 1742.
     f Johnson's Practical Essay on Cancer, p. 110, Phila. edition, 1811. 
110          RESULTS OF  SURGICAL OPERATIONS
character, and  he assures the public that  all the patients but two
recovered from the effects of the operation.
  Mr. Hill  groups  his cases  under two heads;  the first embracing
forty-five, and the second thirty-three cases.   Of the  former, only
one  proved  unsuccessful, meaning, I presume, that the patient died
from the immediate effects of the operation.   In three of the cases,
the  disease  afterwards appeared in different parts of the body; and
in another,  the woman was  threatened with some tumours at a dis-
tance from the original  cancer; but not till  three years after the
excision, when  she died of fever.  All the rest of the patients con-
tinued well as long as they lived, or up to the time of the publication
of Mr. Hill's work.   One survived eleven,  and another thirty years.
  Of the thirty-three cases forming the second group, one lived only
four months, and in five others the cancer broke out again.  Mr. Hill
endeavours to account for the greater fatality  of these cases by stat-
ing that his previous extraordinary success  induced patients to flock
to him from all parts  of the country, compelling him,  often against
his  inclination  and judgment, to operate when  there was but little
probability of success.
  Up to April, 1764, after a practice of thirty years, he had cured
sixty-three patients, of whom thirty-nine were  alive  and sound at
that date.  In twenty-eight  of this number, the  operation  had been
performed more than two years;  in the rest, less  than two  years.
The remaining twenty-five,  which complete the  eighty-eight, were
operated upon  after the year 1764, and of these, twenty-two were
well at least two years.
  In July, 1770, when he had eighty-eight cases, two were not cured;
in nine,  the disease  broke  out afresh, and in  one  a relapse was
threatened;  forming less than  a  seventh part of  the entire  number.
At that time, forty patients were alive and sound, whose cancers had
been extirpated above two years.
  The results of the operations of the late Mr. Nooth,* of England,
seem to have been still more favourable than those of Mr. Hill. His
experience, based upon an extensive practice of thirty years, justifies
him, he says, in declaring that only one in thirty of his patients ever
had  any return of the disease, in any form whatever, after extirpa-
tion of the mammary gland.   The number of  cases reported by him
amounts  to  one hundred and forty-six,  and of this  five only were
unsuccessful!

  * Observations on the Treatment of  Scirrhous Tumours of the Breast, p. 37  se.
cond edition, 1806. 
IN MALIGNANT DISEASES.
Ill
  Mr. Benjamin Bell,* of Edinburgh, who published his celebrated
System of Surgery towards the latter part of the last century, con-
siders that cancer  of  the breast, on its first  appearance, is, perhaps,
in every instance, merely a local affection ;  that the carcinomatous
diathesis is produced, not by any original disease of the constitution,
but by absorption  of the poison from the parts primarily implicated;
and  that, therefore,  every such  malady  should  be immediately re-
moved by amputation, whenever this is practicable.  This, he thinks,
ought  to  be an established' maxim in  the treatment of all cases of
cancer wherever it may be situated, but  particularly when it  occurs
in the mammary gland.   "When practitioners, therefore," says  he,
"have an opportunity of amputating cancerous or scirrhous breasts
early, they ought  always to embrace it.   It often happens, however,
from an improper  delicacy in patients, as well as from  other  causes,
that practitioners are not consulted till the  disease is far advanced.
But although the advantages to be  derived from the operation will
in general be in proportion to the previous  duration of the  disease,
yet, on all  occasions, even in very advanced stages of cancer, it is
right to advise  it, provided the parts affected can  be completely re-
moved."   It may be  added that  Mr. Bell expresses  full confidence
in the statements  of  Mr. Hill, of Dumfries, in regard to the results
of his operations for  malignant disease of the breast.
   Mr. James Latta,f an  Edinburgh surgeon, and  the  author of A
Practical System of Surgery, published at Edinburgh in 1795, was
a decided advocate  of early excision  in cancerous disease  of  the
mamma.   Like  his  countryman, Mr.  Benjamin Bell,  he  thought
that the  complaint was  often of a local nature, and that, therefore,
a radical  cure might  reasonably be  expected, especially when there
is no lymphatic invasion, ulceration, or  adhesion  of the tumour to
the  circumjacent  parts, or great impairment of the general  health;
in which  case,  no operative interference whatever would be justi-
fiable.
   Sir Everard Home relates! the particulars of twenty-two cases of
cancer  of the breast, of which  eight were  permitted to run their
course unmolested.   Of the remaining  fourteen that were operated
on, only five proved completely successful.
   The late Mr. Robert  Allan, of Edinburgh, the  author of an  ex-

           * Vol. ii. p.  437-40, third edition, Edinburgh, 1787.
           f Vol. ii. p. 510.
           X Observations on Cancer, London, 1805. 
112          RESULTS OF SURGICAL OPERATIONS
cellent system of surgery in  its day,* states that,  upon  taking a
review of the  cases of cancer  in which he was concerned,  either as
the operator or as the assistant of Mr. John Bell, and which, at the
time he wrote his work, amounted to a considerable number, he finds
that in the spontaneous form of the disease, occurring in the female
breast about the forty-fifth year, at the cessation of the menses, there
was  a return  of the  affection, either  at the original site or in some
other part, in  at least two-thirds of the patients,  although the knife
was  employed before the lesion  had made  much  progress.   This
result, so unfavourable, led him  to  adopt the  opinion of Monro,
already cited,  respecting the futility of operative interference.  Mr.
Allan thinks that the prospect is  generally better, all  other things
being equal, in cancer of local than in cancer of constitutional origin.
" In the former," says he, " the malady is slow in its progress,  and,
if  removed early, there is usually no  reproduction;  whereas, in  the
latter, it is rapid in its march, and often reappears after excision."
   The character of the late Mr.  Henry Park, of Liverpool, as  an
able, experienced, and scientific surgeon,  is well known to the Ame-
rican profession.  Few English practitioners have stood higher in
their  day in the estimation of their brethren; and hence a  brief re-
ference to his  opinion upon the subject before us will  be  particularly
appropriate on this occasion.  His views of the excision of carcino-
matous  tumours deserve to be recorded as the result  of  an  enlarged
experience and the most careful observation.  In the Memoir of his
Life, by his daughter, f it is explicitly stated that he had  no confi-
dence in the cure of cancer by the use of the knife.  After extirpa-
tion of the mammary gland, he had so frequently seen  the disease
show itself in the  other  breast that  he  was led to  doubt whether
recovery ever  takes place in the genuine form of  the complaint.   It
seems that he had met with no less  than eight cases of carcinomatous
breasts, condemned as incurable, except by operation, by the surgeons
of London, Edinburgh, and Dublin, which all recovered under pallia-
tive treatment, without amputation.  They had been originally under
his care, and  afterwards  returned  to  him  to receive farther advice
and attention.  The disease was, of course, not carcinomatous in any
instance; at all events, it was not so regarded by Mr. Park.
   About fifteen  years ago, namely, in 1838, a very able  and learned
paper on the treatment of carcinoma of the mamma was published

  * A System of  Pathological and Operative Surgery, vol. i. p. 244, Edinb. 1821
  f Transactions  of the Provincial Medical and Surgical Association, vol. vii. p. 479. 
IN MALIGNANT DISEASES.
113
by Dr.  John Macfarlane, of the Royal Infirmary of Glasgow, from
which it appears that, of thirty-two cases of this kind operated upon
by this  distinguished surgeon, the cure Avas not permanent in a single
one.  The ages of his patients varied from forty-two to fifty-nine;
twenty-three were  married, and had children; the rest were unmar-
ried.   In twenty-two the entire gland was affected; and  in  ten  the
disease  existed as a tubercle.   In twenty, the  axillary  ganglions
were  involved, though not extensively, and were removed in the ope-
ration.   In the other twelve, no derangement could be detected in
these structures.   In nine cases, the cancer returned in the integu-
ments of the chest, or in  the axilla, at  a  period varying  from six
weeks to three months  after  the  excision; in thirteen cases, from
three to nine months; in four, from nine to twelve months; in three,
within two years;  and in one, near the  end of the  third year.  In
two of  the cases, the operation proved fatal;  in one, from pleurisy;
and in the other from erysipelas.*
   Besides these examples,  Dr. Macfarlane  ascertained,  on inquiry
among his friends, the results of eighty-six additional cases, in which
this organ was extirpated for well-marked carcinoma, and in not one
of these was the  cure permanent.   In  the majority, the operation
was performed at an early period, and under, apparently,  the most
favourable  circumstances;  the affected parts were thoroughly re-
moved,  and in  many there was no distinct evidence of constitutional
deterioration;  and yet in  every one the disease returned, both ex-
ternally and internally, and proved fatal.
   There  is no writer in the  English  language  whose works have
been  received with more confidence  and respect by the physicians
and surgeons of the  United States than those of Sir Benjamin C.
Brodie.    They bear, throughout, the impress of an honest mind,
great judgment, rare originality, and uncommon practical acumen;
and his  opinions are, therefore, entitled  to much weight, especially
upon  the  subject under  consideration, which has evidently engaged
much of his attention.
   The  cases in which Mr.  Brodief thinks  an operation for the re-
moval of a  cancerous  breast  proper, are, first, where there is no
disease  of the  skin; secondly, where the nipple is not retracted;
thirdly, where  there is no adhesion of the organ to the surrounding

  * London Medical Gazette,  June 2, 1838; Amer. Journ. Med. Sciences, vol. xxiii.
p. 219.
  f Select Surgical Works, p.  214, Phila. 1847.
      8 
114          RESULTS OF  SURGICAL OPERATIONS
parts; fourthly, where there is no enlargement of the axillary gan-
glions;  fifthly, where the  patient is not very far advanced  in life;
and, lastlv, where there is no sign  of internal mischief.  Sir Ben-
jamin states that he does  not intend to say that in these excepted
cases there will be a permanent  cure;  but  he declares that this will
happen  occasionally, and he  adds that the chance pf the occurrence
is sufficient to warrant a resort to the  knife.   He recollects several
persons from whom, under the above circumstances, he removed the
mammary gland, and  who  are now alive and well many years after
the operation, but who would  have  died long  since had the disease
been permitted to pursue its own course.
  He is also  of  opinion that an operation  is proper under other cir-
cumstances.  A hard scirrhous tumour, for example, occasionally forms
on the surface of the breast, but unconnected with its structure, except
at one narrow corner.   He has operated successfully in cases of this
description, without extirpating the gland itself.  Again, a scirrhous
tumour  sometimes originates in the  nipple, subverting its structure,
without seriously involving the mamma  itself.   In  one case of this
kind, in which the whole  breast, although healthy,  was excised, the
woman  was alive and well  many years  afterwards.   In  another
instance, that of a large  elderly female, with a very large  breast,
the  affected  nipple alone  was removed with  chloride  of zinc and
caustic paste,  and the patient was found to be  doing well three  or
four years afterwards.
  Mr. Brodie states that he has occasionally operated  merely with
a view  of  prolonging life,  and relieving the patient from  present
suffering.   He refers to  several cases in which  he happily  accom-
plished this object.
   He thinks  the following circumstances as particularly unfavour-
able to  an operation:  retraction  of  the  nipple ;  ill-defined state  of
the mamma;  a contaminated  condition of the skin, as  indicated  by
its  brawny, anserine, tuberculated,  dimpled,  or  indurated  appear-
ance ;   implication  of the lymphatic  ganglions; ulceration of the
tumour, or its firm  attachment to the integuments, muscles, or ribs •
the coexistence of cancer  in other  parts of the body;  and  deterio-
ration of the general health.
   The  late  Mr. Liston,* in cancer  of the mamma,   recommends
recourse to the knife  as soon as the  malignant nature of the  tumour
is recognized, before  it has made much progress, and  before it has

          * Elements of Surgery, by Gross, pp. 412-13, Phila. 1816. 
IN  MALIGNANT DISEASES.
115
contracted extensive  adhesions, or  contaminated the  lymphatics.
In the latter event, he considers  operative interference scarcely jus-
tifiable.   When enlarged glands  are  perceptible above the clavicle,
or  in  the intercostal spaces, the practitioner who advises inter-
meddling with the original tumour must, he says, be  grossly igno-
rant, or very unprincipled.  Notwithstanding Mr. Liston encourages
a resort to the knife in  the early stage of the malady, he distinctly
declares   that  permanent riddance  from mammary carcinoma  is
scarcely  to be expected  by operation, or any other means.   Neither
does he consider ablation  of  medullary and  bloody tumours of this
gland as more  successful in  its result; though he adds that he has
certainly witnessed permanent  cures under unpromising  circum-
stances,  as when the tumours were large, of  long duration, and even
ulcerated.
  Mr. Herbert Mayo,* formerly surgeon to the Middlesex Hospital,
London,  whose writings  are well known in this country, states that
in  amputation of the  breast, under the most favourable  circum-
stances, that is, at the earliest possible period  after the disease has
declared itself, and before there is any invasion of the surrounding
structures, the malady will return  in  ninety-nine cases out of every
hundred, either at the  cicatrice, or in the adjacent ganglions.  When
the skin  is extensively  implicated, the gland  firmly adherent, the
tumour ulcerated, the  lymphatics much engorged, and the  general
health seriously  deranged, the patient would  not  derive sufficient
benefit from  the operation  to  compensate  him for  the  suffering
attending it.   The time  at which  the malady recurs after  removal
of scirrhus  ranges from six  months to two years, or  even longer.
The changes which supervene in secondary  scirrhus, whether origi-
nating at the cicatrice,  or elsewhere, are generally mild, compared
with the  former.   The constitution, however, sinks more rapidly on
the return of the malady, being by  that time more completely under-
mined than at the first invasion.
  Mr. Syme,f of Edinburgh, in speaking of carcinoma of the mam-
mary gland, remarks  that it would appear,  on the whole,  that the
prospect  of permanent recovery is not so hopeless  as it  has  been
represented,  provided  the operation  is performed only in proper
cases and in an  efficient manner.   Similar  diseases, he continues,
are removed from other parts of  the  body, as the lip, with almost

              * Outlines of Pathology, p. 573, London, 1836.
              f Principles of Surgery, p.  296, Edinb. 1842. 
116          RESULTS  OF SURGICAL OPERATIONS
invariable  success; but  no surgeon  thinks  of cutting  out a cancer
of the lip if there be an affection of the glands under the chin.
  Mr. Travers,* of London, whose name is so well known  in  this
country by his various writings, especially his treatise on Constitu-
tional Irritation, believes  that  cancer  of  the mammary  gland  is
"never curable by excision.  He thinks that he is safe in saying that
of twenty  cases which would, twenty years  ago, have been operated
on by verdict of  a consultation, not five, or not more, would now be
subjected  to it by the consent of the  surgeons."   Generally, when
life is prolonged  by ablation, without  reappearance  of external  dis-
ease,  death finally results from visceral invasion.   Mr. Travers  can
recall to mind instances, exceptional ones, of course, of genuine car-
cinoma, where extirpation was followed by a survival of ten, fifteen,
or even twenty years.
  Sir Astley Cooperf states that the  disease  in a large  proportion
of cases  of excision  of scirrhous  breast returns;  but  not so  fre-
quently as  formerly,  especially if the  patient, immediately after
recovering from the operation, is subjected to  an alterative course of
medicine.    He considers that, in the present state of our knowledge,
extirpation furnishes the only hope of preventing the  malady from
proving destructive, with the exception  of  those  cases which occur
in advanced age, in which it makes little inroad on  the constitution,
and  little  progress in  the parts.   Although  the  patient  may  not
ultimately  survive, yet it  may be said that when the complaint does
return the  operation,  by preventing ulceration, preserves the indivi-
dual from a most painful and offensive  state.  "On  these accounts,"
says he, " I recommend the patient to submit to it.  Hope is revived,
and the only chance for life is given."
  In  regard to medullary cancer of the breast, Sir Astley CooperJ
distinctly states that it is less liable to  return  after  extirpation than
the scirrhous form of the affection, and he therefore  advises an early
resort to  the knife.   The constitution, as after the  operation in
hard  cancer,  requires an alterative  treatment, to  counteract  the
tendency to relapse.
  Mr. Bransby B. Cooper§ is  an  advocate for extirpation of the
scirrhous breast in the earlier and milder forms of the affection;  but

  *  Delafield's Biographical Sketch of J. K.  Rodgers, M.  D. p. 22, New York
1 o -J - .
  f  Lectures on Surgery, by Tyrrell, p. 273, Phila. 1835.
  X  Op. cit. p. 279.
  \ Lectures on the Principles and Practice of Surgery,  p. 565,  Phila. 18-52. 
IN  MALIGNANT DISEASES.
117
m the more active or advanced  cases, the  operation, he thinks, is
rarely successful, even as a means  of prolonging  life.  Under such
circumstances,  indeed, he is of opinion that the operation itself is
sufficient  to  create a further development of  the malady,  and that
the matter which is deposited under the attempted restorative inflam-
mation is cacoplastic instead of healthy; thus leading, as a necessary
consequence, to a propagation of the morbid action to other parts of
the body, quickly followed  by a fatal termination.   Mr. Cooper al-
ludes to the case of a lady who had a scirrhous tumour in one of her
breasts, and who remained quite well for ten years  after  the opera-
tion,  when the complaint returned in  the cicatrice, and ultimately
destroyed her life.   In another case, the disease had not  reappeared
at the end of eight years, though the morbid mass had in this, as in
the  former  instance,  every characteristic  of  the true  scirrhous
tubercle.
   Although this surgeon is averse, as a general rule, to any opera-
tive interference when the tumour is in a  state of ulceration, yet he
seems disposed occasionally, under such circumstances, to  recommend
a resort  to  the knife, with a view merely of relieving the excessive
pains, and checking the exhausting discharges.
   In  respect  to soft  cancer of  the  mammary gland, Mr.  Cooper
states that all remedies, even  extirpation,  are  unavailing.  He is,
however, of opinion that, as the operation removes a great source of
constitutional  irritation,  it  ought  not to be  entirely repudiated, and
the patients abandoned to their fate.   Soft cancer, he says, requires
earlier extirpation  than any other form of malignant disease.*
   Mr. South,  of London, the able editor of Cheliuss Surgery,,f cau-
tions practitioners  against advising patients to submit to an operation
for a scirrhous tumour  of the breast under any circumstances, but
especially when it  is attended with ulceration or  involvement  of the
neighbouring  ganglions.   In no  instance can a cure be  promised;
nor can  it be affirmed that the  person's condition will not be made
 worse by it.   He  does not think, as has often been alleged, that an
 operation will "put off  the evil day," or retard the ulcerative pro-
 cess ; for he has known many examples to the contrary.   The  only
 thin^, indeed, which it can do is to afford  temporary palliation, when
 the patient, as is not very  frequently the  case, is harassed  by severe,
 shooting, stabbing pain, rendering life  almost insupportable.  In
 short he declares that  extirpation  of a  scirrhous breast is, without
* Op. cit. p.
5J3                         -j- Vol. iii. p. 540, Phila. 1847. 
118          RESULTS OF  SURGICAL OPERATIONS
doubt, the most  unsatisfactory proceeding in the whole  course  of
surgical practice.
  Mr. Birkett, the  author of an excellent work on the Diseases of
the  Breast and their  Treatment, published in London  in 1850, is
rather favourably disposed to  operation in mammary cancer, espe-
cially in its  first stage of  development,  before the  tumour has
acquired any  considerable bulk, while  the adjacent  structures are
still  sound, and  the  general  health continues  unimpaired.   The
chance of success diminishes as the  disease advances, and in what
Mr. Birkett calls  the fourth stage of the complaint, characterized by
ulceration and other severe symptoms, he considers operative inter-
ference inadmissible, even as  a means of prolonging life.

                 §  4.  VIEWS OF FRENCH AUTHORS.

  Under this head, I shall content myself  with citing the views and
recommendations  of the leading systematic  writers of France during
the last fifty years.   Of these, one of the  most respectable and in-
fluential  is Baron  Boyer, whose celebrated  TraitS des  Maladies
Chirurgicales  was for a long  time the principal  authority  upon the
subject  in that country, and which will always  remain  as a monu-
ment  of the learning  and science  of that great and excellent sur-
geon.
  The result  of  the experience of this author* upon this  subject
strikingly coincides with that of  Monro, given in a preceding page.
Of upwards of one  hundred cases of supposed cancerous tumours  of
the mammary  gland and other parts of  the body, operated upon by
him, there were only four or five in which the cure was radical; in all
the others the  disease recurred after a longer  or shorter period, and
proved fatal.   He  is  of opinion that ablation is frequently useless
and even detrimental, and that, in many of the cases in which  it  is
said  to have  been followed by permanent relief, the affection was  in
reality not cancerous, but strictly benign in its character.
  The circumstances  which,  in the judgment of Boyer,  justify a
resort to the knife,  with a prospect  of a favourable  issue,  are, first,
the recent standing, small size, entire mobility, and indolent charac-
ter of the tumour; secondly, where the disease can be traced to some
external cause, as a blow, or contusion; thirdly, where the axillary
ganglions are not  enlarged; and, fourthly, where the patient is young,

  * Traite" des Maladies Chirurgicales, t. v. p. 585. Cinquieme edition, Paris, 1846. 
IN MALIGNANT DISEASES.
119
perfectly healthy, menstruates regularly, and is free from all heredi-
tary taint.  The chance of success is much more uncertain when the
tumour is old, bulky, and painful; when it arises without any evident
cause;  when it appears at or before the critical period;  and when it
is attended with marked derangement of the uterine functions.   The
case is hopeless when the tumour  involves the whole or the greater
portion of the breast; when it is flattened and of stony hardness;
when it is ulcerated,  or  attended with retraction of the nipple, or
enlargement of the lymphatic  ganglions, or  when it  coexists with
similar disease in other regions of the  body; and, finally, when it
occurs in a female who is forty, or upwards  of  forty years of age,
who is descended  from  cancerous parents, and who has  ceased to
menstruate, or menstruates irregularly.   Under such circumstances,
Boyer concludes with  Monro that extirpation  should be  undertaken
only at  the  most urgent solicitation of the  patient,  to whom the
danger of a relapse should always be carefully explained beforehand.
   The views of Mons. Vidal* so  nearly  agree with  those  of Boyer
that it would be superfluous to present them  in detail in this place.
A rapid abstract must, therefore, be sufficient.
   A relapse  after  operation, says this writer, is  the most frequent
result; one, indeed, generally to be looked for, either at the original
site of the malady or  elsewhere.   The circumstances which are most
favourable to the success of operations,  and which should,  therefore,
be regarded as indications for its performance, are, the youth of the
patient, the regularity of the menstrual function, an external excit-
ing cause, the absence of hereditary taint, the recent standing of the
complaint,  the small volume and mobility of the tumour, freedom
 from enlargement of the axillary ganglions, and the presence  of but
 little  cellulo-adipous  matter in the  breast.   Ablation  is contra-indi-
 cated when the tumour is old, voluminous, ulcerated, or spread  over
 the whole breast;  when it is  complicated with engorgement of the
 lymphatic ganglions;  and when it occurs at the approach of the criti-
 cal period, or is  attended with  great irregularity of the  menstrual
 function.   Considered separately, however, these circumstances do
 not  in  the  opinion of Vidal,  absolutely forbid the operation any
 more than when the mamma is  flattened  and of stony hardness, when
 the nipple is retracted, and when the patient  is  descended from can-
 cerous parents;  circumstances which, according  to Boyer and his
 followers, preclude all hope of  success.  In short, he thinks that

   * Traite" dc Pathologie Externe, t. iii.  pp. 804-5.  Troisieme edition, Paris, 1851. 
120         RESULTS OF SURGICAL OPERATIONS

one  or more of these symptoms may be present, and yet the opera-
tion have a favourable issue. When the tumour is adherent, whether
to the integuments or  muscles, the prognosis is very unfavourable,
and should always seriously arrest the attention of the surgeon.  No
one  ought to  operate when the disease extends  to the  intercostal
muscles and bones of  the  chest.
  Be'rard and  Denonvilliers,*  speaking of cases  of cancer  favour-
able for operation, express themselves almost  precisely in the same
language  as Boyer and Vidal.  The small size, circumscribed cha-
racter, superficial situation, and  perfect  mobility of  the tumour,
together  with  its recent formation, and its development under  the
influence of some external  and appreciable cause, the soundness of
the cutaneous  covering, and the absence of engorgement of the lym-
phatic ganglions, are so many indications for the employment of the
knife; while the reverse of these circumstances are so many contra-
indications.   These writers consider  the coexistence of several tu-
mours, and those tumours which result  from relapse, as particularly
unpropitious to a successful issue.
  There  is, according to these writers, a class  of cancers in which it
is  never  prudent to employ the knife, although they appear  to be
exempt  from most of the complications which render  the issue of
the operation  doubtful.  These are  scirrhous  cancers,  very  chronic
in their progress, occurring in old  persons, causing hardly any pain
or functional disturbance, producing no detrimental impression upon
the  constitution, and  remaining indefinitely  stationary, or, at all
events, until some external injury, or indiscreet medication, revives
their activity.   An operation, under such circumstances, might no
doubt succeed; but in depriving a patient of  a malady which  occa-
sions so little inconvenience, the benefit which it confers would hardly
compensate for the dangers attendant upon its execution.f
  Mons. VelpeauJ considers the removal of scirrhus of the breast pro-
per  only when the disease is entirely circumscribed in  its character;
or,  in other words, when the malady is strictly confined  to the gland,
when there is  no engorgement of the axillary ganglions, and when
the internal organs are perfectly sound.  "We may hope," says he,
" for a complete success if the scirrhus be  lobular, perfectly circum-
scribed, and easily enucleated.  But we should expect  such  a  result

  * Compendium de Chirurgie Pratique, t. i. p. 696, Paris, 1840.
  f Op. cit. t. i. p. 698.
  X A Treatise on the Diseases of the Breast. Translated by Dr. Parkman. Pp. 61-62
Philadelphia, 1841. 
IN  MALIGNANT DISEASES.
121
with but little confidence in a case where the  scirrhus is  ramified,
radiated, or of the simple or disseminated ligneous species."  Under
such circumstances, the  operation  might be  performed with a view
of prolonging life for a few months, or of ameliorating the patient's
suffering;  but beyond this no benefit would  accrue from it.   In
speaking  of encephaloid, Mons. Velpeau declares that, in  extirpat-
ing it, we have only to fear its reproduction with renewed intensity.
  J. B. F. LeVeiHe*, of Paris, the author of a treatise on surgery in
four volumes,* teaches  that the  prognosis  in cancer, whatever may
be its nature, is always extremely unfavourable; for, says he, on the
one hand, there is no medical treatment that can resolve the disease;
and, on the other,  the success of our operations is so uncertain that
many of the most reputable practitioners advise against their adop-
tion on the ground that, in the true form of the malady, they are
never of any permanent  benefit.   It is true, he continues, that the
parts may heal; but they either reopen, or they become the seat of
new tubercles after six months, a year, or several years; so that the
affection  is  merely suspended,  not annihilated.  Notwithstanding
this, Le'veille is in favour of extirpating scirrhous tumours, when they
are a source of great and constant suffering,  as a means of  prolong-
ing life.   Speaking of the numerous patients  operated on by Desault,
and many of whom he  carefully watched, this author declares that
none survived at the time  of the publication of his work in 1812.
One only lived fourteen  years, and  died  in  1806 with an  enormous
carcinoma in the other breast, complicated with  enlargement of the
mesenteric ganglions.
   Richerand, the elegant author of the Elements of Physiology, and
of a celebrated work on  Surgery, f removed  a large number of can-
cerous breasts with variable results, but, on  the whole, so encourag-
ing that he may justly be ranked among the advocates for  this ope-
ration.   Two circumstances, according to this writer, contra-indicate
this proceeding, namely, too great an extent of the local vice, and  a
general  cancerous infection.   If the breast is adherent to the ribs,
immovable, and as it were glued to the  anterior wall of the chest, it is
not  possible to determine the depth of its roots, and, consequently, it
might be impracticable to effect the total ablation of the morbid sub-
stance  without which success could not, of course, follow the opera-
tion.  Such a case, therefore, formally contra-indicates such kind of

  * Nouvelle Doctrine Chirurgicale, t. iv. pp. 98-99, Paris, 1812.
  + Nosographie et Therapeutique Chirurgicales, t. iv. p. 381.  Cinquieme edition,
Paris, 1821. 
122          RESULTS OF  SURGICAL OPERATIONS

interference.   Mere engorgement of one or  more of the  axillary
ganglions on the affected side  does not forbid  the  use  of the knife;
but the reverse is the case when the lymphatic invasion exists in the
opposite  axilla, inasmuch as it evinces a general cancerous infection,
and  the  malady  soon  recurs, spreading with more  violence and
rapidity than if no operation had been performed.  Nor does  great
adhesion  of the  tumour  to  the  wall  of  the chest,  according  to
Richerand, contra-indicate the  use of the knife, inasmuch as expe-
rience  has proved that the patient may be  cured, even when we are
obliged to remove the great pectoral muscle and scrape the ribs.

       §  5. VIEWS OF GERMAN, DUTCH, AND DANISH AUTHORS.

  The views of the surgeons of these countries, upon  the results of
operations in malignant diseases, do not  differ, so far as  I have had
an  opportunity of  making  myself acquainted with them,  in any
essential manner,  from  those of the  practitioners  of  other  parts of
Europe or of  the  United States.   While some, especially those who
flourished in  the  latter half of the  last century,  speak  rather  en-
couragingly of  the use  of the  knife, others are so  much  dissatisfied
with it that they have  thrown  all  their influence into  the opposite
side of the scale,  denouncing the remedy, except in a very few rare
instances, as cruel, improper, and even unjustifiable.   The startling
and  interesting observations adduced by David  Van  Gescher,  of
Holland, seem to have first aroused the attention  of the  physicians
and  surgeons of Northern  Europe to  the  uncertain,  if not futile,
nature of excision as a curative agent in cancerous affections.   In
his  Treatise on Carcinoma, published  at Amsterdam  in  1767,*  he
gives, from his  own experience and that of others, numerous cases of
this operation, in  not one of which a radical or permanent cure was
the result.  It is  worthy of remark, however, that most of  these
cases Avere examples of open cancer,  or cancer in its more advanced
stages, in which, as is well  known, no  mode of treatment that has
hitherto  been  devised,  answers  any  other  purpose than that of a
mere palliative.   Similar views had been previously promulgated  by
Trieler, Van der Haar, Kaltschmidt, Damen, De Wind, and Uhorn;
and since then the same kind of doctrine has been taught by Theden,
Siebold,  Kapp, Vogel,  Rust,  and nearly every modern  author  of
Holland  and  Germany.  In  1789, the  Chirurgical Society  of Am-
* Proeve over de Vornaamste Langduurige Gezwellen, Amst. 1767. 
IN  MALIGNANT DISEASES.
123
sterdam offered a prize of fifty ducats (a sum which was subsequently
doubled) for a well-authenticated case of a  complete and unexcep-
tionable cure of carcinoma, either in its occult or ulcerated stage; but,
strange to say, not a single candidate presented himself, such was
the state of the science upon the  subject at that period.
   In 1772, Peter  Bierchen* published a treatise at  Stockholm,  in
which, after inveighing against cicuta and other remedies, he strongly
insists on the utility of extirpation, especially when performed early
in the disease.  When there is ulceration of the tumour, or lymphatic
invasion, he considers it as an  evidence that the growth has taken
too deep root, and that, consequently, an operation would only has-
ten  the fatal  result.   P. Van  Esch,f of Gand,  in  1772, and J.  C.
Bauer,J of Hersfeld, in 1773, published each  some successful cases
of amputation  of  cancerous  breasts.  J. L.  Schmucker,§ the cele-
brated Prussian surgeon, also about  this period, wrote in favour of
the use of the knife, and narrated several  cases in illustration of  its
beneficial effects.  It would appear that  he had performed the ope-
ration a great many times, for he was a man of much reputation and
extensive practice.  Schmucker  entertained some  singular notions
on the subject of carcinoma  of the breast, and the removal  of this
gland by  the knife.  Thus, for example, he  declares that the opera-
tion rarely, if ever, succeeded when  there was inflammation of the
edges of the eyelids.   His experience, indeed, had taught him that
the existence of this complaint was a sign  of a contaminated state of
the  fluids,  and, therefore,  highly unfavourable to a radical cure.
F. T. Oehme,|| of Warsaw, and  Deneke,! of Stralsund, both pub-
lished, about the same time, the results of some successful cases.
   The celebrated  anatomist  and surgeon,  Peter  Camper,** of Ley-
den, was  an advocate for operative interference  in mammary carci-
noma.  He advises that the knife should  be resorted to at an early
stao-e of the disease, before there is any involvement of the axillary
ganglions, or serious disorder of  the  general health.   He made it a
rule never to operate, however favourable the other symptoms might
be, when the patient complained of a fixed  lancinating  pain  in the

   * Introedes tal om Kraftskoeder, Scrophuloese och Veneriskesor, och Swulnaderg,
Stockholm, 1772.
   + Heelkondige Vaarnemingen, Gand, 1772.
   + Zwei Chirurg. Warnehm., Hersfeld,  1773.
   t Chirurgische Warnehmungen,  th. ii.  p. 51.
   5 Observ. einer Scirrheusen Frauenbrust mit offnem Krebs, Warschau, 1774.
   f\ C. C. Lerche, Diss. Observ. do Cancro Mammae, Gcetting. 1777.
   ** Genees-Natnren  Huishondkondig Kabinet, No. 3, p. 194,  1779. 
124          RESULTS OF SURGICAL OPERATIONS
chest, between  the  second and third ribs, which, of all the contra-
indications, he considered as the most important.  He avers that he
was never deceived  by this sign, and hence he never disregarded it
in his practice.
   A. T. Richter, the  author  of the celebrated  Anfangsgrilnde  der
Wundarzneykunst,* expresses the opinion that extirpation  of  the
mammary gland would succeed more frequently, if it were not  re-
garded as a last resort, and if it were employed before  trial is made
of other remedies.   It rarely,  however,  succeeds, even  in occult
cancer, and hardly  ever in the ulcerated form of the affection.  The
best means of preventing relapse  is to heal  the wound by the first
intention.  Richter recommends  the removal of the whole breast,
and also all enlarged lymphatic ganglions.
   C. L. Schmalz,f  of Leipsig, asserts that the extirpation of an in-
dolent scirrhous tumour  of the  breast is  generally followed by  the
happiest results.  The cure, on the other hand,  is seldom permanent
when the operation  is postponed until the part is very painful, while
a  relapse may  always be expected when ulceration has  occurred.
Gerret Jan  Van WyJ insists upon the indispensable  necessity of
amputating  cancerous breasts, and states that he himself, in  one
instance, happily performed  the operation where  the  malady was
attended with enlargement of the axillary  ganglions.
   Henry Callisen,§ of Copenhagen, the author of a celebrated work
on surgery, published towards the  latter  part of the  last  century,
thinks that early and prompt ablation is  required, especially in can-
cer of the breast, on account of the multiplicity of lymphatic vessels,
and the  consequent danger  of  contamination  of the neighbouring
structures.  At a more advanced period,  and particularly when  the
malady has been developed without any obvious cause, after the  age
of forty,  there is always repullulation, after operation, at the end of
several  years,  if not sooner.  He  states that he saw hardly  one
woman survive  of  all  those  upon whom he  had operated who were
more than thirty years of age.   From this remark, we may conclude
that most of  his cases were followed by a return of the complaint.
   The brothers  Wenzel, Joseph and Charles,|| two  eminent German
anatomists, saw a great number of breasts  amputated by Wiedmann,

         * Vol. iv. p. 386.
         f Seltene Chir. und Medicinische Vorfselle, Leipzig, 1784.
         X Heelkondige Mengelstoffen, Amsterdam, 1784.
         § Princip. System Chir. Hodierna, pars ii. p. 132.
         || Arnemann's Magazin, b. ii. s.  3, p. 336. 
IN  MALIGNANT DISEASES.               125
and nearly all  the patients  remained cured.  Several, in whom the
wound had been long cicatrized, had a relapse, dependent, seemingly,
upon  some peculiarity of the skin and adipous tissue.  In no instance,
however, did the secondary  tumour attain the volume  of the  primi-
tive one; so that, although farther  removal might be  improper, the
first operation generally subserved the purpose, if nothing more,  of
a palliative.
   Dr. Lawrence Heister,* Professor  of Physic  and Surgery in the
University of Helmstadt, is in favour  of  extirpation  of the mam-
mary gland,  provided there is no disease of  the integuments, or  of
the adjacent lymphatic  ganglions.   In that case, he remarks, the
operation will  not  cure  the  patient; for  the virus  of the  cancer
which lies  concealed in other parts  will in a short time induce a re-
currence  of  the  disorder.  Notwithstanding this,  there  are some
instances, though they are rare, in which these bodies  are indurated,
and yet excision is followed  by a complete cure.
   The late  Dr.  C. B. Zang,  Director  of  the  Surgical Clinique of
Berlin, and the author of a  large work  on  Operative Surgery,,f con-
siders the  following circumstances  as contra-indicating excision  of
the breast: first, the existence of a cancerous dyscrasy, as  evinced
by the state of the skin, and the presence  of fever, cough, pain
behind the sternum, emaciation, and tendency to thoracic effusion;
secondly, infection  of the adjacent lymphatic ganglions, especially
those of the axilla, although  an instance occasionally occurs in which,
when this  is  the case, the operation is  successful; thirdly, firm and
extensive adhesions of the tumour  to the pectoral muscle; fourthly,
the rapid development of the  morbid growth, or its steady and per-
sistent progress; fifthly, the  coexistence of the malady in other
organs; sixthly, its hereditary origin;  and lastly, an  open state of
the sore.   If when these contra-indications are absent, an operation
is decided upon, it  should be performed as early as possible, before
any precious time has been  lost by vain attempts to cure the  disease
by internal remedies.  Zang, however, looks upon extirpation  merely
as a palliative, no matter how early or how thoroughly it may be ex-
ecuted ; because  cancer, in  his opinion, is  always  a  constitutional,
and not a  local affection.
   In the article on  cancer  of the  mamma  in Rust's Handbuch der

   * A General System of Surgery, vol. ii. p. 61. English Translation, London, 1768.
   f Darstellung Blutiger Heilkiinstlerischer Operationen, dritter theil, p. 83, Vienna,
1818. 
126           RESULTS OF  SURGICAL OPERATIONS

Chirurgie, published at Berlin, in 1830,* it is stated that extirpation
of the affected organ is the only remedy that holds out any prospect
of permanent cure, and that this, unfortunately, is  but  very rarely
successful.  The operation  is recommended to  be performed very
early in the disease, before there is any constitutional contamination,
or derangement of the catamenia.  When the  tumour  has  made
great progress, is hereditary in its origin, or is attended  with retrac-
tion  of the  nipple, adhesion of the skin, ulceration, enlargement of
the axillary lymphatic ganglions, disease  of a similar character in
other parts  of the  body, as the uterus, or suppression of  the menses,
all hope of  success from excision is at an end, and should, therefore,
be refrained from, inasmuch as it can do the patient no good, and will
only bring surgery into discredit.   Rust himself, f one of the most
eminent and experienced surgeons of his day, had no confidence in
extirpation  of  cancerous  breasts;  on the contrary, he felt satisfied
that it never could  effect a permanent cure, and insisted upon it that,
whenever  such a  result occurs, there is some mistake  in  the dia-
gnosis of  the case.
  Professor Chelius,| of the University of Heidelberg, one  of the
latest and  most respectable German writers  on surgery, says that
the only remedy for  scirrhus of the  breast is  its removal  by  the
knife, and the earlier this is done  the more favourable may the result
be expected to be.   Where the disease is already somewhat advanced,
and where the nipple is retracted, the general health disordered, and
the menstrual function irregular, or entirely arrested, the result of
the operation is doubly doubtful.   Still, it is the  only remedy to pre-
vent ulceration.   Where this process is already established, where
there is hardening of other  organs,  and where the tumour is firmly
attached to the surrounding parts, extirpation will be utterly useless;
at all events, it can do nothing more in such a case than a palliative.
Chelius has not noticed a more  rapid progress after the operation,
but,  on the  contrary, considerable relief for a lono- time.
   Of ninety-eight amputations of the breast, performed  for carcino-
matous disease at  the surgical clinique of the University of Breslau,
by Professor Benedict,§ two ended fatally from exhaustion soon after
the operation;  and in all  the rest, except thirteen, the malady re-
turned after the wound was  cicatrized, and destroyed  life.   With

  * Vol. iii. p. 520.
  f Handbuch der Chirurgie, b. iii. p. 438.
  + System of Surgery, translated by South, iii. p. 539, Phila. 1847.
  i Rust's Magazine, No. 2, vol. xliv.; Amer. Journ. Med. Scien. vol. xvii p. 513,1835. 
IN  MALIGNANT DISEASES.
127
regard to those that recovered, Dr. Benedict expresses his conviction
th*.t,  in several  at least, there was an error in the diagnosis, the
gland being affected with scrofulous, or some innocent disorder.
   Of the many operations performed for the removal of cancerous
breasts by Professor Pockels,  of  Germany, a single one  only had a
favourable termination.  The tumour, in this instance,  was considered
to be  identical with ^hat of reticular carcinoma, first described  by
Muller, of Berlin.*

                 § 6. VIEWS OF ITALIAN AUTHORS.

   But little is known, in the United States, of the surgical literature
of Italy; few of our physicians are acquainted with the  Italian lan-
guage, and hardly any one visits that country in quest of  professional
information.  The surgical sun of  that once favoured and  enlightened
land, the home of poetry, philosophy, and the arts, has  never risen
since the death  of the illustrious Scarpa, whose fame was coexten-
sive with the European  and  American Continents.  The principal
surgical writers of Italy, during the last fifty years, are  Monteggia,
Palletta, Flajani, and,  above all,  the great surgeon whose name we
have just mentioned.   From  these, therefore, we shall gather what
information is necessary to the illustration of the present subject.
   The  views  of Monteggia,f respecting extirpation of cancerous
breasts, do  not differ materially  from those  of the French writers,
especially Lassus.   He agrees with this author that the  operation is
improper when  the  malady is complicated  with adhesions of  the
tumour to the circumjacent parts, enlargement of the axillary gan-
glions, severe cough,  and difficulty  of respiration.  He enjoins it
upon his readers that the knife should always be carried  through  the
healthy tissues, and that the whole gland should be removed, however
limited the  heteromorphous deposit.   He also lays much stress upon
the  importance  of preserving a sufficiency of integuments to secure
union by the  first intention, or, at all events, the  speediest possible
closure  of the wound.   In speaking of  carcinoma in general, Mon-
teo-gia remarks that few patients  escape relapse after the complaint
has made some progress ; for, in  that event,  the shock of the opera-
tion  superadded to the baneful impression which the cancerous poison

   * Muller on the Nature of Cancer, by West, Part I. p. 84, London, 1840.
   f Lnstituzione- Chirurgicale, vol. vii. p. 212, second  edition, Milano, 1815.   See,
also, vol. ii. cap. xx. 
128          RESULTS  OF SURGICAL  OPERATIONS
has made upon the system, will almost certainly induce such a result,
and that at an early period.
   After extirpation  of a  carcinomatous breast, Monteggia* recom-
mends the establishment of a large issue in  the corresponding arm,
with  a view of maintaining a  discharge of pus at least for several
years, if not during  the remainder of life.   Desault, he says, who
neglected this precaution, allowed the general  health to take care of
itself, and  the  consequence was that most of his  patients soon
experienced a relapse of the disease.
   J. P. Palletta, who wrote on  cancer of the mammary gland  at an
early period of his professional career, considers  scirrhus, even  in
its incipiency, as a mere local manifestation  of a constitutional dis-
order, particularly when it is not  produced by any external  cause.
He was in favour of early operations, and  thought it  of no special
advantage  to save much integument; on the  contrary, he was in the
habit of removing the skin freely whenever he found it much attenu-
ated or otherwise diseased; and he made it a rule, moreover, always
to excise the entire  organ.  His advice is never to extirpate an old
carcinomatous tumour, or one which  is complicated with disease  of
the chest, or with a cancerous diathesis.   His opinion, founded upon
the result of personal experience, was that all operations of this kind
are, in general, merely  palliative measures.f
   Scarpa| thought that extirpation  of the  cancerous  tumour could
be performed with a prospect  of success only in  the earlier stages
of the malady, while there is  yet an absence of sharp, lancinating
pain,  and the morbid deposit is  still a  mere  germ,  without  any con-
stitutional  disorder.  The  chance of  success is greatly diminished,
if indeed not wholly destroyed,  if the surgeon wait until the disease
has made much progress, or until there is enlargement of the axillary
ganglions,  or a carcinomatous cachexy.  His opinion on this subject
seems to coincide nearly with that of Palletta.   Scarpa believes that
the surest way of preventing relapse consists  in removing, along with
the affected gland, a large portion of the neighbouring tissues, which,
although apparently healthy, are not so in reality, but usually con-
tain  some  cancerous matter, and thus serve as  a nest for the repro-
duction of  the malady.   Thus, for  example, if  the tumour were not
larger than a fist, he advises  that  at least twice  that  amount  of

     * Op. cit. vol.  vii. p. 213.
     f Weigel's Italiaenische Bibliothek, th. iii. st. 2,  p. 199, Leipsig, 1797.
     X Practical Observations on Cancerous Complaints, London 1793. 
IN  MALIGNANT DISEASES.
129
substance should be removed, in order to place the parts in the best
possible  condition  for  a permanent cure.   It would seem that this
great surgeon, in the course of his long practice, met with only three
cases of  cancer  where,  after operation, there was no repullulation.*
  Joseph Flajani,f a modern Italian surgeon, was a decided advo-
cate  for  operative  interference in  all  cases  of cancerous  breast,
unattended with disease of the chest, violent pains  in the arm, and
enlargement of the axillary ganglions. His opinion was that, although
the  malady might occasionally be resolved, yet such a  termination
was so infrequent that  it should not be considered as an  objection to
the use of the knife.  Advising that the operation should be performed
at as early a period as possible, he remarks that in twenty-seven
cases in which  this  suggestion was  adopted he met with only two
where there was any recurrence of the morbid action.  He considers
it of no  particular advantage  to husband the integuments, or to fa-
vour union by the first intention.  On the contrary, he seeks to pro-
mote suppuration and  discharge by keeping the wound open, lest the
matter should be confined, and thus produce mischief in the surround-
ing  parts.   His experience has taught  him  that relapses are more
frequent  after prompt  than after tardy closure of the parts.
   Although Flajani prefers to  operate early in the  disease,  yet  he
does not consider the  use  of the knife as positively contra-indicated
in the ulcerated form of the malady.  Of several females who were
subjected to this  treatment, under these circumstances, four were
cured, one died of consumption, and  two retained their cancerous
sores, but lived comfortably a long time.  In every instance in which
the disorder involved  the entire gland, or which was attended with
sharp lancinating pain  in the  chest and  neighbouring parts, with
fever and  enlargement of  the axillary ganglions, or where the affec-
tion showed itself as a consequence of the suppression of the menses,
or  some  other  habitual evacuation, the operation infallibly hastened
the death of the patient.

  * Compendium de Chirurgie Pratique, par Berard and  Denonvilliers, t. i. p. 694,
Paris 1840.
  |  Collezione d'Ossero et  Riflessione, t. i. p. 256;  Sprengel, Hist, de la Medecine,
t. viii. p. 486.
9 
130          RESULTS OF  SURGICAL OPERATIONS
                SECT. II.—CANCER OF THE  EYE.

  The most common  forms of malignant disease of the ball of the
eye, and the only ones that require any notice in this report, are
encephaloid and  melanosis.   The variety  of  soft cancer, first de-
scribed by Mr.  Hey under  the name of fungus hsematodes, is by no
means infrequent, but as it generally occurs in combination with the
encephaloid deposit it does not seem to me to be entitled, in any way,
to separate consideration.   Most pathologists and morbid anatomists
of the present day agree, if I mistake not, in regarding the two affec-
tions as mere subdivisions of one and the same growth.  Of scirrhus,
properly so termed, I have  never seen an instance in this organ, and
I doubt whether there is  a  well-authenticated  case of  it on record,
notwithstanding what has been said about it in the books.
  Melanosis and encephaloid, with their different varieties, are most
common in young subjects,  and they generally run their course with
great rapidity, often terminating fatally  in six or eight  months, while
very few live beyond a year  or a year and  a  half.  When  extir-
pated, the disease  invariably  returns;  or, if this  remark  be too
sweeping, it reappears so generally and so constantly as to render
all surgical interference absolutely worse than  useless.  I am certain
that nothing could ever induce me again to undertake the extirpation
of the globe of the eye in any case, either for encephaloid or mela-
nosis.  When I was a student in Philadelphia, I saw the late Pro-
fessor  McClellan remove  this organ  in three  instances for these
affections, and  in each there was  a reproduction of the  malady in
less than a month.  The patients were children  under nine years of
age, and in two,  the  symptoms and  progress of the malady were
such as to hold out strong inducements  for operation.  I have extir-
pated the ball of  the eye in eight  cases, in six for encephaloid. and
in two for melanosis, and in every one,  so far as I have been  able to
judge, I believe that I have done  mischief, by hurrying the patient
prematurely to  the  grave.   In one instance  I  performed not less
than three operations almost  in so many weeks, first removing the
eyeball, and then portions of the lids and neighbouring parts, but all
to no purpose.  My patient died from the effects of the malady in a
few months from the time of the  first  excision.   Some years ao-o I
saw a young  gentleman, aged about thirteen, upon whom Professor
Mussey, of Cincinnati, had  already operated twice, with the effect of a 
IN MALIGNANT DISEASES.               131
speedy relapse in each instance.   When the case fell into my hands,
some weeks after the last operation, the morbid growth had already
made such rapid strides  as utterly  to preclude  the  propriety  of
farther interference.   The youth went home, and died a few months
after.
  Anxious to ascertain the views  of the surgeons of our ophthalmic
institutions, I addressed, early in  the progress  of my labours, letters
to a number of them upon  the subject, but regret  to say that two
only have responded to my call, namely, Dr. Littell, of Philadelphia,
and Dr.  Bethune, of Boston.  The former of  these gentlemen, who
has been so long connected with Wills Hospital, informs me that his
experience respecting extirpation  of the eyeball is  actually less than
that of many surgeons in private practice; for it would seem  that the
nature of the  complaints, and the  concurrent testimony of our  ablest
writers to the inutility of surgical interference have precluded him,
in  cases clearly malignant,  from  subjecting his patients to a pro-
cedure which  gives so little  promise of  success, and which, in  many
instances, could hardly fail to accelerate the fatal event.
   " My  own  observation," continues  Dr. Littell,  "abundantly con-
firms the unfavourable prognosis  so unanimously given; every case
of fungus  hsematodes of the orbit, and of medullary or encephaloid
disease of  the globe—maladies  improperly   confounded  by  many
authors—which I have traced to its termination, having had  intra-
cranial origin or connection  which utterly precluded all hope of per-
manent  relief.  In  one instance,  the morbid growth seemed to arise
from the sphenoidal cells ; in another, of fungus hsematodes  mani-
festing  itself  by an elastic swelling, simulating an  encysted tumour,
below the  upper margin of the orbit, it was  attached to the dura
mater-  and in a third, of medullary disease of the eyeball, there was
extensive alteration  of the  optic  nerves,  and  a large tubercle lying
on  the optic  chiasm, though no  indication was afforded of  grave
cerebral affection until  comparatively a  short time prior to dissolu-
tion."
   Dr. Littell  states explicitly that he never extirpates the eyeball in
any case of malignant disease;  nor, so far as  he is aware, is  the
operation ever performed by any of his colleagues at Wills Hospital,
with two of whom, Dr. Hays and Dr. Parrish, he has been associated
since the opening of that institution in 1834.
   Finally   Dr. Littell thinks  that, in the treatment  of medullary
disease, attention to the general health, by placing  the patient  under
the most favourable hygienic influences, with the alterative action of 
132          RESULTS OF  SURGICAL  OPERATIONS

some of the  preparations of iodine, as  the  iodide of iron and the
compound tincture of iodine, may have  some effect in retarding the
progress of the symptoms.   In an instance  recently under his  care
it  appeared  plainly beneficial.   His experience, however, is too
limited, it would  seem, to enable him to  speak confidently on the
subject.
  The subjoined  cases of malignant disease of the eye  and  orbit
have  been communicated to  me by Dr. George A. Bethune, surgeon
of the Massachusetts Charitable Eye and Ear Infirmary.

  Case I. Colloid Tumour  of the Orbit.—The subject of this case,
a blacksmith, aged thirty-five, had generally enjoyed good health.
In 1832, he had an attack of inflammation of both eyes, which have
remained weak ever since.   Five years ago,  he noticed a pterygium
at the inner  angle of the left organ, followed  by impairment, and,
finally,  by complete  failure,  of  the sight.   For  two  or three
months  past  he had occasional  "twinges"  in this  eye, and an in-
creasing  " blur."   When first seen by Dr. Bethune, in May, 1847,
the globe was pushed outwards and forwards,  and the pterygium,
which was thick and vascular, extended partially over the  cornea.
A similar formation existed on the right eye.   Connected with the
base of the pterygium in the left organ was an elastic tumour, which
filled the inner commissure of the lids, and which was  more pro-
minent below than above.
  On the 14th of May, the tumour, which  extended deeply into the
orbit, and adhered closely to the bone, was removed along with the
globe, as it was impossible to separate them in the dissection.   The
eye was perfectly healthy.   The tumour, of the size of an English
walnut, consisted of a soft gray substance, made up of large jelly-like
granules, and was considered by Professor J. B. S. Jackson  as  a
specimen of true colloid cancer.  The parts  gradually healed, and the
man was discharged on the 30th of October, in good health.   He was
seen nearly two months after, without any appearance of relapse.

  Case II. Melanosis of the Globe.—Mrs. G.,  forty-three years of
age,  has generally enjoyed good health till within  the last six years,
when she began  to have pains at her catamenial periods.  Three
years ago, she was found  to  labour under  a  uterine polypus, which
was  removed.  Twelve months  previously, she was taken with pain
and redness in the right eye, succeeded, by degrees, by total loss of
vision.  In June,  1847, the anterior half of  the globe projected in 
IN MALIGNANT  DISEASES.
133
the form of an irregular fungous mass, half an inch beyond the lids;
the tumour was of cartilaginous hardness in  front, and of a mixed
white and red  hue; behind, it was of a mixed black and red ; and,
still farther back, there was a shot-like tubercle, nearly black, with a
livid tint.  The remainder  of  the globe was much injected, but not
enlarged, and a sanious discharge exuded from its surface.   The eye
was extirpated on the 18th of June, and in a month  after, although
the wound was  not completely healed, the general health was good.
In December, the disease returned in the orbit, and probably proved
fatal soon after.
   The eye was but little enlarged, except at the point  already men-
tioned;  it was everywhere solid, and, instead of its humours, there
was a firm, dark, brownish mass, of an irregular figure.   Posteriorly,
there was  a  whitish substance,  of  a gristly  consistence;  the optic
nerve was spotted black, and the sclerotic coat was much altered in
its texture.

   Case III.  Carcinoma of the Eye.—A farmer, aged seventy-four,
who had ordinarily enjoyed good health, observed  a red spot  on  the
sclerotic coat of the right eye, which gradually increased, and soon
acquired the volume of a small pea;  it commenced about two lines
from the outer edge of the cornea, and was accompanied with unusual
vascularity of the adjacent parts.   The remainder of the ball was
perfectly sound, and the sight was unimpaired.   The operation, per-
formed  early in November, 1849, presented  nothing extraordinary,
and in a few weeks the man was discharged cured.  When  last heard
from  in  December, 1851,  there was  no return  of  the complaint.
The tumour, examined microscopically, exhibited  strongly, but not
decisively, the usual indications of malignant disease.

   Case IV.  Melanosis of the Eyeball—A. farmer, sixty-eight years
old, noticed,  twenty  years ago, a red spot on the outer corner of the
left  eye,  which  gradually  expanded into a pterygium; this, after
having long remained stationary, began to pain him,  and to increase
in size, ultimately obstructing the sight.  On  examining the organ,
in February, 1850, a tumour, of a wedge-shape, black, smooth, and
irregular, was found to project from its anterior surface, so as to
separate the lids.  Extirpation was performed on the 12th of  the
month and the  patient left the Infirmary on the 20th, the wound
beino- only partly healed.   On  the  20th of  June, when  last seen,
he  was improving, without  any indication  of relapse.  Under the 
134          results  of surgical operations
microscope, the tumour  presented, first, numerous  cells, apparently
epithelial in their  character; and, secondly, a great many cells of
irregular outline,  containing sub-cells and nuclei; also, some of a
marked caudate figure,  and an immense number of black granules,
some isolated,  and some aggregated into masses.

  Case V. Melanotic Tumour of the Ball and Orbit.—A gardener,
aged thirty-six, whose general health has usually been good, was
attacked, sixteen months ago, after getting wet, with pain in the left
eye, extending to  the back of the head, and accompanied with red-
ness and soreness.  These  symptoms have continued at intervals
ever since, and have been followed, at first, with gradual, and finally
with complete loss of sight.  About six months ago the ball gave
way, and began to enlarge until  the present time;  it  is  now disor-
ganized,  and forms a mass  of  the size of a  small  apple,  which
projects between the lids, and is encircled, in part, by a firm, irre-
gular  ring.  The  organ  was extirpated on the 17th of September,
1850.  There was some hemorrhage, but this was easily arrested by a
tampon; a great deal of swelling and suppuration followed, and the
man was not discharged until the 17th of October.  When last seen,
July 11, 1851, there was no appearance of a return of  the malady.
  The globe of the eye was altered in its form, but not enlarged, and
was filled by a uniform black mass.   The cornea was nearly effaced,
the sclerotica was much changed, and the humours were destroyed.
On the outside of the ball was  a large mass similar to that within.
The remainder of the  growth, forming the larger part of the tumour,
varied remarkably in colour, some portions being white, some gray,
and others black  or grayish-black.   There was no appearance of
encephaloid.   The optic  nerve could not be distinctly traced.
         SECT. III.—CANCER OF THE GUMS AND JAWS.

  The very singular  growth, to which the term  epulis is usually
applied, is generally obscure in its character, and consequently diffi-
cult  of  diagnosis.  Experience teaches that certain forms of this
affection, which have not, however, been hitherto well described, are
of a fibrous, or fibro-plastic structure, and,  therefore, comparatively
harmless, giving rise, perhaps, merely to some pain and functional
disturbance.  Occasionally, however, the growth  is  of a  scirrhous
nature, and  sometimes, though very rarely, it  is found to  be en- 
IN MALIGNANT  DISEASES.
135
cephaloid.   In either case, the progress  and symptoms are such as
usually attend these formations in other parts of the body.
  The only remedy for scirrhous epulis is excision, performed at the
earliest possible moment  after its appearance.  As the tumour gene-
rally springs from the socket of one of the teeth, ordinarily a grinder,
mere  ablation of the soft parts will not  suffice; to be effectual, and
unfortunately this rarely happens even  under  the most favourable
circumstances, the corresponding  portion of the bone must  be re-
moved at  the  same time, not only far  away from the disease, but
in its entire thickness.   Partial excision  is worse than useless.   The
following case, which seems to have been originally of a  scirrhous
character,  and which may be considered as typical of  this form of
cancer, strikingly illustrates the hopeless character of the complaint,
and the utter futility of  excision as a curative measure.
   Mr.  S., a  tall, slender man, aged  thirty-two,  of Allen County,
Kentucky, consulted me in April 1851, respecting a tumour of the
lower jaw, which  he first observed three months previously.   Com-
mencing in a  soreness  of the gum  round  the  last grinder of the
right side, it was soon  succeeded by a small  red, tender swelling,
which gradually increased  until  it was  the  size of the  end of the
thumb, when  it was cut out by a physician in the  country.  In two
weeks the  tumour, now fully three times as  large  as before, was re-
moved a second time, along with the  last grinder,  the root of which
was much  diseased.
   When the patient reached Louisville, the tumour formed two large
 cylindrical masses, one  on each  side of the dental arch,  of a pale
red colour, devoid of pain, elastic, and of firm consistence,  extending
 from  the  ramus  of the jaw to the first bicuspid tooth.  The cheek
 was round and unchanged in form; but just beneath the angle of the
 bone  the  parts were  hard  and swollen, in consequence  of  recent
 suppuration.   On the 27th of April, I removed  the morbid mass,
 along with all that portion of the jaw which lay between  the bicus-
 pid tooth  and the ascending ramus.   Slight erysipelas followed the
 operation, but the wound soon healed, an'd the patient went home  in
 a fortnight.
   Early in September, I learned  that the gap left by the removal of
 the bone was occupied by a tolerably large mass, quite hard, and the
 seat of  a  constant  discharge  of pus.   The  tumour was steadily in-
 creasing  but was free from pain and soreness.  On the 24th of the
 month °I  operated  upon him a second  time, removing  the whole of
 the new growth,  which was now as large as a pullet's egg,  and about 
136          RESULTS OF SURGICAL OPERATIONS
three-quarters of an inch  of the  anterior extremity  of the  ramus
of the jaw, as this  supported the diseased structure.  The wound
healed well, except at a  small point, which remained fistulous for
some months, owing to the  difficulty of keeping its  edges approxi-
mated in the first instance.   On  the 2d of July, 1852, the patient
informed me that he was in good health, and that there was not the
slightest appearance of disease of any kind.
   Soon after receiving the above  intelligence,  however, the malady
began to show itself again, in the form of  a tumour at the anterior
extremity of the ramus of the jaw, which soon acquired the volume of
a pullet's egg, and became the seat of sharp stinging pains, darting
about in different directions.   It was very dense and  firm,  of a  pale
colour, and quite tender on pressure.  The jaw in front of the tumour
was sound,  and the general health excellent.
   On the 31st of August I  excised the ramus  at  the articulation.
The  wound united by the first intention, and the man  returned home
in a  fortnight, apparently in perfect health.   The morbid growth,
scarcely as large  as a  pullet's  egg, and of a dense firm  structure,
partly fibro-cartilaginous,  and partly  osseous, was attached to  the
inner surface and anterior extremity of the bone, the latter of which
was  unnaturally thin and slightly notched^  The external surface,
neck, condyle, and coronoid  process were  all sound;  but  the inner
surface,  nearly as far  back  as the dental foramen,  was  somewhat
roughened and thickened, from the effects of the disease.
   Early during the past winter, this relentless  disease returned  just
in front of  the  ear, forming  a rapidly increasing tumour, which is
at this time, April 2,  1853, nearly the volume of an  ordinary  fist.
Of course,  further interference is out of the  question, though  the
general health remains pretty good.
   When epulis  presents  itself in the encephaloid form,  whether
primarily or secondarily, no  operation, however early resorted  to,
will be likely to result in anything but failure.
   Scirrhus of the jaw bones must be exceedingly rare, as I have  not,
in a  practice of twenty-five- years, met with a solitary case.  Many
instances of the  kind  are,  I am aware,  reported in  our surgical
and periodical literature; but a careful examination of them fully
proves that they were examples, not of hard  cancer, but  of ence-
phaloid, or  of fibrous, fibro-plastic, and fibro-cartilaginous  growths.
Melanosis is also  very rare; perhaps  still more so  than  scirrhus,
while colloid is  more frequently met with, especially in  the lower 
                   IN MALIGNANT  DISEASES.               137

jaw, in what has been  described  under the vague names of osteo-
sarcoma and spina-ventosa.
   By far the most common disease of the upper jaw, of its body,
as well as of its sinus, requiring operation, is encephaloid, which, in
whatever form it may begin, or  at  whatever age it  may seize its
victim, always terminates fatally, whether it be permitted to pursue
its own course, or whether an attempt be  made to  arrest it by exci-
sion.  Here again we have to lament  the  want of reliable statistical
tables, showing the results of surgical interference in a given number
of cases of extirpation  of the  diseased structure.   Of eleven  cases
operated on by  Lizars,  Syme,  Robert, Scott, Earle, Guthrie,  and
Hetling,  only one was completely successful.   Was  that one  of a
malignant character ?   The late  Mr. Liston removed  the upper jaw
in seven  instances, in only one of which  the  malady returned, and
proved fatal.  Dieffenbach relates five successful operations; Gensoul
three,  and one of failure; Rignoli had one successful case, and one
case of failure.*
   Who can  doubt  that  the above  cases,  designated  as  successful,
were of  a malignant  character?   No  intelligent, scientific,  and
experienced  surgeon could, I am sure, come to such a  conclusion.
Hence, these cases lose  much of their value in a practical point of
view; because they cannot serve as a safe guide in future  operations.
One great misfortune in regard to nearly  all morbid growths of the
upper jaw is the difficulty of diagnosticating  them;  and  so long as
this  difficulty exists will surgeons be likely to report as cases of
cancer  formations  of the  most simple  and  innocent  description;
the excision of which must necessarily be followed by the  permanent
cure of the patient.
   Looking at my own cases of excision  of the upper jaw, seven in
number,  I find that four have terminated fatally; two from a recur-
rence  of the disease, one from pneumonia, and one from  dysentery;
that two have entirely recovered; and that  one has suffered a relapse,
but  is still living five years  after  the extirpation of the morbid
growth.   In this  case,  that of  Mrs. Green,  I  excised  nearly the
whole of  the upper jaw in 1847;  and since then several pieces have
been removed, at different intervals, on account of a recurrence of
the complaint, by Dr. Sloan, of Indiana.   Although the  tumour, in
this instance, was not inspected with the microscope, yet I am certain,
from a careful examination of its physical properties, that it  was
* Brit, and Foreign Medical Review, vol. vii. p. 250. 
138          RESULTS OF  SURGICAL OPERATIONS
cephalomatous in its character;  a circumstance which imparts more
than  ordinary interest  to  the case, inasmuch as it holds out  en-
couragement  to the  surgeon in an  affection usually  regarded  as
desperate, if not hopeless.*
   It is proper to state that in  one  of the above cases, marked as
having recovered, the disease for which excision was  performed was
not malignant, while the tumour in the other possessed  all the phy-
sical properties of encephaloid.   I saw the subject of the latter case
four years after the operation, when she was perfectly well.
   The most  common form of malignant disease of the lower jaw is
encephaloid, which, judging from my own experience, is much more
frequent in childhood and adolescence  than at any other period of
life.  Indeed, the very worst cases  that I have seen occurred  before
the tenth year, and ran their course with a rapidity truly frightful.
Most persons thus  affected die within six or eight months from the
commencement of the attack; and  if  an attempt be  made to relieve
them by operation, the malady is almost sure to return in a very short
time, either at the cicatrice, or in the adjacent structures, especially
the lymphatic ganglions.  The  prognosis  is  here, if possible, still
more unfavourable than in medullary disease of the upper jaw.f


              SECT. IV.—CARCINOMA OF THE LIP.

   Cancer  of the inferior lip—for  it  is  this organ that this disease
nearly always implicates—may be  of the  true carcinomatous cha-
racter, or it may be purely cancroid.   The  relative frequency  of
these two maladies has  not  yet  been determined, though it is well
ascertained that they are most  commonly met with in old persons,
and that they are much more frequent in the male than in the female.
Practically, it would be interesting and important to know how to
discriminate between cancerous  and  cancroid affections of the lip;
but upon this subject our knowledge is too imperfect to enable us to
arrive  at any positive conclusions. All that can be said, with any
degree of certainty, is  that  genuine carcinoma of the lip always
returns after extirpation, whereas the  epithelial form of the malady
is  not  unfrequently curable by the knife,  and sometimes also, but
more rarely, by escharotics.

  * Gross on Excision of the Upper Jaw, in Western Journ. Med. and Surg. vol. x.
p. 207, third series, 1852.
  f Western Journ. Med. and Surg. vol. x. p. 278, 1852. 
IN MALIGNANT  DISEASES.
139
  I have been at some pains to illustrate this branch  of the  subject
by a reference to cases; but after having ransacked all the periodicals
at his command, Dr. D. D. Thomson, of this city, to whom it was con-
fided, assures me  that he has not been able to find more than three
well-reported examples  of  extirpation of  cancer of the lip upon
record.  The first of these cases is  related by  Mr. Cline,  in the
second volume of  the London Lancet, for 1828-9.   The  patient, a
blacksmith, between sixty and seventy years of age, had no return
of his disease twelve years after the  operation.   The affected parts
were hard and ulcerated, and the glands under the chin were enlarged
to a great extent.  The other cases are mentioned by Mr. Loyd, in
the  same periodical for 1850, but are  deficient in their details.  In
one of the cases, the operation had been performed nine or ten years
ago, and in the other thirteen years ago, without any relapse.  Mr.
Loyd, in the same communication, refers to two other cases of cancer
of the lip operated upon long ago, without any untoward occurrence.
   Dr. Benedict,* Professor of Surgery in the University of Breslau,
mentions fifty-one cases in  which the lip was removed at the surgical
 clinique of that city, and which were all successful, except one, where
the patient was in a state of great weakness at the time of the opera-
 tion.  He regards the operation, however, merely as a palliative
 measure, as the disease invariably returns, either at the cicatrice or
 in some other part of the body.   In  a few cases, in  which there was
 no  relapse,  he  supposes that the disease was  strictly local, or pro-
 duced by some external cause, and not of a genuine cancerous cha-
 racter.   He also asserts, contrary to  the generally received  opinion
 among  modern  surgeons,  that  the  absence of  tumefied ganglions
 under the jaw or in the neck does not justify a favourable prognosis;
 alleging that these bodies,  or the lymphatic vessels communicating
 with them, usually become implicated  at an early stage of the malady,
 and thereby predispose to a  relapse in the event of a resort to the
 knife.
    I subjoin the following facts,  in further illustration of the subject:
 John Shipley,  aged fifty,  was  admitted into  the Louisville Marine
 Hospital, July 21, 1842, on account  of a tumour  of the lower lip,
 which made its appearance seventeen months before, in the form of a
 small wart.   About eight weeks after it was first noticed he pulled
 it out  and applied  lunar-caustic to  the part; but it soon  began to
 grow again, and, gradually increasing in size, at length became ulcer-

    • Rust's Magazin, No. 2, vol. xliv; Amer.  Journ. Med. Scien. vol. xvii. p. 513. 
140          RESULTS  OF SURGICAL OPERATIONS
ated, and the seat of a severe burning and  darting pain.   At the
time  of his admission, the whole margin  of  the lip was indurated,
and  covered with a fungous growth, discharging a  thin, sanious,
and  highly offensive fluid.   On  the  26th of  July, Dr. Dodson, one
of the surgeons of the hospital, assisted by Dr. T. L. Caldwell and
myself, extirpated the affected structures by a free incision, embracing
nearly the entire lip from one angle  of the mouth to the other, and
extending fully as low down as the commencement of the chin. Seve-
ral vessels having been tied, the gap was filled with lint,  and the
wound soon healed by the granulating process.   It should be stated
that there was no disease of the gums or jaw, nor  any enlargement
of the neighbouring  lymphatic ganglions.  The tumour was of a
firm scirrhous consistence; and the patient was very feeble and ema-
ciated, at the time of the operation, from pain and loss of appetite
and sleep.
   I saw Shipley again in July, 1851, nine years after the above ope-
ration.   His health had been perfectly re-established, and no tend-
ency to relapse had ever manifested itself  in  the remnant of  his lip,
which was  perfectly soft and pliant.  As  he was constantly  obliged
to wear a band around his mouth to confine the saliva, he  had lost,
from  the  pressure thus occasioned, the lower incisor  and the right
cuspid and bicuspid teeth;  but the gums  and jaw  were  entirely
sound.  The object of his visit to me was to get me to make him a
new lip, which I accordingly did by the sliding process.
   In  1846, I excised the central portion of the lower lip, embracing
about one-half of the organ, from a gentleman of the  name  of Fol-
some, aged about forty, of Point Commerce, Indiana.   The  tumour
was about the size of a pigeon's egg, hard and firm in its consistence,
and the seat of a sharp, lancinating pain;  it had begun in the form
of a small chap or fissure, which had existed for many years, and had
been a source of much annoyance.   The  general health had never
suffered.   This gentleman had no return of his  disease in October,
1852, when I last saw him.
   In the following case, the  operation was performed  by Dr. B. W.
Dudley, of Lexington.  The patient was  the venerable  and much
respected  Dr. Gait, recently of this city, now of its vicinity.   The
tumour appeared in 1820, and continued  to  increase for six years,
when it was destroyed by powerful escharotics by the late  Dr. Har-
rison, of Bardstown, Kentucky.  The disease seemed to be completely
eradicated, but some time after it returned, and continued to harass
the patient until May, 1830, when it was excised by Dr. Dudley. 
                   IN MALIGNANT DISEASES.               141

Since  then the lip  has  remained  perfectly well.   Dr. Gait is now
upwards of seventy years of age.
   Professor Eve informs me that he has removed  the whole of the
inferior lip for what was supposed  to be  a  cancerous  affection  in a
man aged  eighty, and that three years  afterwards  his mouth, cheek,
and neck  remained perfectly free from  the disease.   In a case of
this affection, operated on by Professor Pope, of St. Louis, the parts
retained their healthy condition; but cancer formed in the lung, and
destroyed  the patient.
   The tables of Professor Hamilton, of Buffalo, contain five cases
of cancer  of the lower lip, all occurring  in elderly subjects, and all
followed by relapse, either immediately or at  a period more or less
remote from  the operation.  In  one case, that of a man of forty,
the  disease began in  the form of  a wart, and  was destroyed by the
actual cautery ; it returned, and after  it had remained as an  ulcer
sixteen years the potential cautery was applied; it reappeared  again
in a month, and, spreading rapidly, was removed with the knife.
The patient  had remained well five years, when  Dr. Hamilton re-
ported the case.
   In another case, the cancer was seated at the commissure of the
lips.   The patient was thirty-eight years of age, and the  disease had
made its appearance two years before in the form of a fissure.   The
parts were excised, and  the gap  was closed by anaplasty.  Imme-
diate relapse was the result.
   There is reason to believe, as I  have  already stated,  that genuine
carcinoma  of the lip  nearly always, if not invariably, returns after
ablation.   "It is matter  of common  belief,"  says Mr. Walshe,*
" that  the  lip is one of the situations in which the excision of cancer
may be undertaken with the strongest hopes of success.  There can
be no  question that the  prevalent notion on this point is  an exagge-
rated one, and has arisen in consequence of syphilitic  sores having
been cut away  as cancers."  Mr.  Walshe has in some instances
known the disease repullulate, after apparently the most thorough
excision  in two or three months;  and in a case which he  observed
in 1834, in the  practice of Dupuytren, the progress and fatal issue
of the affection were obviously  hastened by the use of  the knife.
Velpeau  saysf it is important to operate freely and early in cancer-
ous tumours of the lip; otherwise, they return in the neighbourhood

  * On the Nature and Treatment of Cancer, p. 258, London, 1846.
  f Operative Surgery, by Mott and Townscnd, vol. iii. p. 345, New York, 1847. 
 142         RESULTS OF SURGICAL OPERATIONS

 and beneath the jaw with frightful rapidity.   He relates the case
 of a robust peasant who died on the ninth day after the removal of
 a small cancerous excrescence from the lower lip, in whom, although
 his general  health seemed to be good, hundreds of cerebriform gra-
 nules were found in the liver.
   The tables of Mons. Leroy D'Etiolles, of Paris, contain the results
 of 148 operations for cancer of the lip, of which 126 were performed
 upon males, and 22  upon females.  Of the  former,  114 were by
 excision, and 12 by caustic; the relapses were  15, that is, about one-
 eighth of the entire  number.  The 22  other operations were per-
 formed with the knife, and were followed by 7  relapses ; that is, one-
 third of the entire number.   Thus, it would seem  that  cancer of
 the lip is more liable to recur after operation  in the  female than
 in the male, in  the proportion of upwards of one-half.*  It is diffi-
 cult, however,  to  say what reliance should be placed upon  these
 tables, or whether they should be received at all as evidence in regard
 to the absolute  and relative liability of cancer of the lip  to  return
 after extirpation.  In France, to the inhabitants of which they refer,
 and where  their accuracy can be  best appreciated, very little  con-
 fidence appears  to be put  in  them  by Mons. Leroy's professional
 brethren.
  A good case  of carcinoma of the lip, in which the gap, produced
 by the operation, was filled by cheiloplasty, and in which there was
 no return at the end of the third year, is  related by Dr. Stout, of
 Easton, Pennsylvania, in the Philadelphia  Medical Examiner  for
 January, 1850.  The disease had commenced about five years before
 in the form of  a fissure,  and gradually  involved  the whole of  the
 lower lip, extending from one angle of the mouth to the other, nearly
 as far down as the base of the chin, and spreading over about one-half
 of the upper lip.   The four inferior incisor teeth, together with  the
 corresponding portion of the gum  and jaw were removed with  the
 tumour, which  was very thick and hard, but not painful.   There
was no enlargement of the neighbouring lymphatic ganglions.   The
patient was  fifty-three years  of age at the time of the operation in
November,  1844, and there was no evidence of relapse  in  April,
 1848, when  the case was published.
• Amer. Journ. Med. Scien. vol. viii. p. 244, 1844. 
IN MALIGNANT DISEASES.               143
                SECT. V.—CANCER OF THE PENIS.

   The penis is occasionally the seat of malignant disease, chiefly in
aged subjects; and the form in which it most commonly presents
itself is the  scirrhous.  Encephaloid  is extremely rare, both  as  a
primary and secondary affection; and,  as to melanosis and colloid, I
am not aware that any cases of these morbid products have ever  been
noticed here.  We have no statistics of malignant diseases of the penis,
throwing any valuable light upon the results of operations  undertaken
for their relief.   In my own practice, I have generally declined in-
terference, for the reason, first, that most of the cases  which  have
fallen under my observation were too far advanced to justify a resort
to the knife; and, secondly, because I have never had any confidence
whatever in the curative agency of excision in genuine cancer of this
or  any other part of  the  body.  I have  very  lately performed the
operation upon a gentleman, aged sixty-one, in  whom the small  size,
the recent  standing, and the circumscribed character of the tumour,
as well as the total absence of lymphatic and constitutional invasion,
augured most favourably, but who, nevertheless, was threatened  with
a  return of the disease in less than five weeks.   The extirpation in
this case was most thorough, the knife being carried through the body
of the organ far behind the gland, upon the upper and back part of
which the morbid growth,  hardly six lines in diameter,  was situated.
   Under proper treatment—consisting of  a purely vegetable and
milk diet, mild laxatives, and great attention to  cleanliness—patients
with scirrhus of  the  penis will, I presume, generally  live quite  as
long and as comfortably without  as with an operation.   In several
cases, with the history of which I am acquainted, life was not destroy-
ed until more than three years after the appearance of  ulceration of
the tumour and enlargement of the lymphatic ganglions of the groin;
a period seldom attained by individuals undergoing operation.
   The tables of Professor  Hamilton, annexed to this report,  refer to
three cases of cancer of the penis in which amputation  was followed
by  relapse, respectively,  at  six, twelve,  and  twenty-four months.
Dr. Warren's paper contains  nothing  definite  upon the results  of
operation in the cases therein described.  In one of the cases, re-
markable for  its hereditary character,  the man died eight  months
after the amputation.  This patient's father, grandfather,  and great-
grandfather, all  died of cancer of the penis. 
144          RESULTS OF  SURGICAL OPERATIONS
  Professor Walshe*  affirms that experience strongly exposes the
inefficacy of excision in cancer of the penis.  "When the disease,"
says he, "is actually established, removal  of the  morbid mass with
the knife  would  appear to afford  the only  chance of saving the
patient; and, unfortunately, this chance is a singularly sorry one.
General experience corroborates the statement of Mr. Travers, that,
'if  the penis be amputated  at  some distance beyond  the  hardened
part, and before the disease has existed long, the patient may escape
a return of it;  but this is a rare instance of good fortune? "  *   *
"For my own part," continues  Mr. Walshe, " I can find no recorded
case of permanent recovery after amputation of  the  penis  for un-
questionable cancerous disease."


             SECT. VI.—CANCER OF THE TESTICLE.

  Scirrhus of the testicle is exceedingly infrequent.  In  fact, almost
the only well-authenticated case of this form of carcinoma is that
described by Sir Astley Cooper, in his Lectures on Surgery, by Mr.
Tyrrell.   The  patient was  forty-four  years of  age, and the organ
was extirpated  nine months after the first appearance of the  disease.
The wound healed kindly enough, but the thigh and  leg, which were
oedematous at the time of the  operation, remained swTollen,  and the
man died a month after his  return  home.   Melanosis  and colloid
rarely attack the testicle, and  I do not know of  any cases in which
the gland was removed for these affections.
  The most common form in which malignant disease of the testis
presents itself, is  the encephaloid,  fungoid, or  cerebriform.  The
malady here, as elsewhere, is always  fatal when left to itself.   The
only remedy is amputation, and this, unfortunately, is  nearly con-
stantly followed by relapse in a very short time.   I have performed
several operations for this form of carcinoma, without, I am satisfied,
benefiting my patient in the slightest degree, except, perhaps, in so
far as temporary relief from pain was  concerned.  The disease, in
every instance, promptly returned, either at the  original site  or  in
some  other part,  and rapidly  proved  fatal.  Mr.  Curling statesf
that he has scarcely known a solitary example of castration having
been  performed for this affection in which  the patient  survived for
any lengthened period.  Of five cases recorded by Sir Astley Cooper,
there was not  one in which there was  not a recurrence of  the dis-

  * On the Nature and Treatment of Cancer, pp. 411-12, London, 1846.
  f A Practical Treatise on the Diseases of the Testis, p. 378, Philadelphia, 1843. 
IN MALIGNANT DISEASES.
145
ease; and Sir Benjamin Brodie, in his large experience, never knew
but one patient whose life was  prolonged by the operation beyond a
few years.
   Dr. Otto Baring,  of  Hanover, in Europe, seems  to entertain a
more favourable opinion of excision in this affection than the majority
of English writers.   In his elaborate  Treatise on Medullary Fungus
of the Testicle, published in 1833, and comprising  the most complete
body of facts that has yet been furnished on the subject, he gives the
particulars of several cases  in which the operation was performed,
with the most gratifying results, by Rust, of Berlin, Langenbeck, of
Gottingen, and Hagedorn, of Stade.  In two of these cases, a period
of five years, in another, of three  years,  and in a fourth, of two
years, had elapsed since the removal of the organ, and  yet there
was not the slightest  appearance of relapse, or of constitutional  de-
rangement.   Dr. Baring considers castration proper  in all  cases
where the disease is of local  origin, or the result of external violence,
and where the system remains free  from contamination.   Even in
enlargement of the ganglions of the groin, he thinks  an  operation
not wholly inadmissible; whereas, such a step is  altogether unwar-
rantable when the  disorder  has  extended to the  spermatic cord, or
affected the constitution.
   Professor Pope, of St. Louis, has excised the testicle  in four cases
for encephaloid.   "The  only one," says he, "that I know of  now,
has the other  gland affected like the first."
   An instance in which  the patient, aged thirty-five, has  remained
well for at least twelve years after the extirpation  of an encephaloid
testicle, came  under the  observation of Dr.  J. B. Flint,  of this  city,
in 1840  and is recorded in a former volume of the  Transactions of
this Association.   Although  the wound  healed kindly,  yet the man
continued weakly for  many months, but  finally recovered  under the
use of tonics, and was well  when the case was reported  in April,
1850.
   In the table of Dr. Forsyth, accompanying this report, and drawn
up at my request, twenty-two out of the twenty-seven  cases are
stated to have been fatal; of the rest, in one, the disease returned; in
one  the result is not given; in another, the patient  remained well five
months after the  operation; in a fourth,  the man was enjoying good
health at the  end of two years;  and of the other,  no report was
made after the first month.   Three of the cases are marked as  scir-
rhus  and of these  one recovered, that is, he was  alive at the end
of a'month.   AH the other cases were encephaloid.
       10 
146
RESULTS OF  SURGICAL OPERATIONS

    Table of Twenty-seven Cases of Malignant Disease of the
Resi-
dence.
 9

10


11


12


13






14
46






40




48

44






25


 5

 1

 1



 4

27


34
Worces-
ter.
Rams-
bury.
London.
Rother-
ham.
Potten-
ham.
Cam-
bridge.

London,
15
28
18
Edin-
burgh.
Dura-
 tion.
4 mo's
Rapid
2 mo's
lOmo's
1 year
9 mo's
Pro-
 Mode of
operation
Castra-
tion.
Structure.
Encepha-
loid
Scirrhous
Encepha-
loid
Death
Return

Death
Not
given

Death
I  times  as
large as na-
tural.
Hen's egg.
8 times  the
size  of  the
other testicle
Goose egg.
Surgeon.
A. Cooper.
Dr. Black-
 man.
A. Cooper.




Mr. Lunn.

A,. Cooper.





Okes.


Cline.

Earle.

Langstaff.

Cline.


Cruveilhier.


Curling.


Hunter.





Newbigging
Dr. Thomp-
 son. 
IN MALIGNANT  DISEASES.                   147
Testicle.   By Alexander Forsyth, M. D., of Louisville.
Authority.
Postmortem examination.
Cooper on Testis,
 p. 156.
Cooper on Testis,
 p. 159.
Cooper on Testis
 p. 160.
Cooper on Testis
 p. 162.
Cooper on Testis
 p. 169.
Cooper on Testis,
 p. 179.

Curling on Tes-
 tis, p. 368.
Curling on Tes-
 tis, p. 368.
Curling, p. 368.

Curling, p. 372.
Curling, p. 372.


Curling, p. 375.


Curling, p. 382.
Wardrop on Fun
gus Hsematodes,
p.  134.
Wardrop, p. 139.
  A tumour behind the duodenum, and one
in the loins, of a white, fibrous, and brain
like substance, as large  as the head of  a
child;  mesenteric glands  enlarged;  aorta
nearly closed by a fungous  secretion.
  A large tumour, of a pale white colour, curd-
like matter, and of the consistence of cream
filled  nearly  the whole  of the abdominal
cavity;  the liver contained two white tuber-
cles ;  thoracic viscera healthy.
  Abdominal viscera more or less  affected
with the same disease.
  No post mortem reported.
  The abdominal  cavity presented,  in all
directions, large irregular masses of a soft
pulpy structure.


  Brain and other parts similarly diseased.

  The lumbar glands, lungs, and dura mater
were affected with same disease.
  A large tumour in the loins, which had
affected the vertebrae so as to press upon the
spinal cord.
  The sixth and  seventh cervical vertebrae
and the posterior  extremities of the first and
second ribs, diseased in the same way.
  A large tumour was  found in the abdomi
nal cavity, resembling coagulated milk with
whey in it; the colon,  stomach, and other
viscera, were connected by a similar tumour;
the liver was  filled with small tumours of
the same kind.
  Spermatic cord indurated; a large tumour
surrounded the  aorta and vena cava,  of  a
soft consistence and a dark-brown colour;
the liver contained tubercles of a blackish
colour;  in the pelvis of the kidney, a quan-
tity  of purulent  matter was found;  the
lungs were tuberculous.                 _
  Spermatic  cord  sound;  the lymphatic
glands along the lumbar vertebrae very much
enlarged;  when cut into were found of white
colour and soft consistence.
  A  few months  after
the operation, the pa-
tient died with legs and
thighs  swelled, a  large
tumour in the abdomen
&c.
  This patient died ten
weeks  after the opera-
tion.
  The  testicle in  this
case presented a hard,
white,  compact, tuber-
culated, and, in  some
parts,  very  vascular
appearance.
  This patient died 13
months after the opera
tion.
  The   patient  died
paralytic.

  This patient also died
of paralysis.

  The  history  of this
case is not given com-
plete.
  This was  a case  of
carcinoma of the tunica
vaginalis.
  This patient died on
the tenth day after the
operation. 
148
RESULTS OF SURGICAL OPERATIONS

                                  Table of Malignant Disease
33
Edin-
burgh
Massa-
chusetts
18
27
19
30
20




21


22

23




24


25




26






27
35
54
36
50
Resi-
dence.
Louis-
ville
England
Fall
8 mo's
30 y'rs
Dura-
 tion.
2 y'rs
3 y'rs
2 y'rs
9 mo's
2 mo's
1 year
4 mo's
 Pro-
gress.
 Mode of
operation,
Castra-
tion
Very
slow
Slow
Rapid
Encepha-
loid
Scirrhous
45
Death
Reco-
very

Death
Reco-
very

Death
Large as two
 fists.
Wardrop.
J.  C. War-
 ren.
Large.
J. C. War-
 ren.
Turkey egg.
Goose egg.
Hen's egg.
Goose egg.
Surgeon.
J.  C. War-
 ren.
J. B.  Flint.




Lawrence.


Lawrence.

Langstaff.




Langstaff.


Brown.
Reco-
very
Key.
Key. 
                       IN  MALIGNANT DISEASES.

of Testicle—Continued.
149
Authority.
Wardrop, p. 140.
Warren on  Tu-
 mours, p. 331.
Warren on  Tu-
 mours, p. 332.
Warren on  Tu-
 mours, p. 334.
Alex.   Forsyth
Lancet, vol. ii
 1846-7, p.  444,

Lancet,  vol.  i.
1829-30, p.  828.
Lancet,  vol.  i.
 1835-6, p.  405.
Lancet,  vol.  i
 1835-6, p. 407

Lancet,  vol.  i
 1836-7, p. 639
Lancet, vol.  ix,
 1825-6, p. 138.
Lancet,  vol.  i.
 1826-7, p. 14.
  A chain of glands extended from the in-
ternal ring (very much enlarged) to a large
diseased mass situated  on the lumbar ver-
tebrae;  this mass'was pulpy—some parts as
soft as cream, others firmer than brain.

  No examination  of the body.  The  au-
thority thinks the abdominal organs were un-
doubtedly diseased, but  attributes the death
to internal erysipelatous inflammation.
  The membranes of the brain covered with
lymph;  the ventricles contained water;  the
lungs inflamed,  and contained many tuber
cles;  abdominal viscera not diseased.
Postmortem examination.
  The body greatly emaciated;  the abdomi
nal cavity contained water;  a knot of scir-
rhous glands  extended from the groin to
the aorta, which was buried in a mass of
enlarged  and  softened  glands;  the right
lung tuberculous and indurated;  left lung
partially diseased in same way.  Brain not
examined.
  A large  brain-like  tumour in  the  pelvic
cavity;  a chain of diseased  glands reaching
from the groin to the stomach; pyloric ex
tremity of the stomach diseased in the same
way;  the brain and lungs not examined.
  No examination.  Thoracic viscera sup
posed to have been diseased.
  The absorbent glands in the lumbar region
affected with same disease;  left lung much
diseased in  same way;  a large tumour  on
the internal portion of the parietal  bone;
other viscera healthy.
  This testicle weighed
two pounds; the whole
gland converted into a
pulpy mass, none of the
natural structure :
maining.
  This patient received
the  injury  when  17
years old; the swelling
continued occasionally
until  4 months  before
the operation; then be
came  permanent  and
very painful.
  Seven years before the
operation, this patient
felt pain in the testicle;
had swelling; occasion-
ally after had  pain and
swelling; 2 years previ-
ous to operation swell-
ing became permanent
No examination.
Remarks.
  This case has never
been reported; I am fa
miliar with its history,
and have the tumour in
my possession.
  Five  months  after
there was no return of
the disease.
  This patient  lived a
year after the operation,
  The patient was in
good  health two years
after  the operation.
  This patient was pa
ralyzed in the lower ex
tremities before death;
a large tumour could be
felt in the abdomen.
  This is reported  true
scirrhus,  although no
operation had been per
formed when the  case
was diagnosed.  (Diag
nosis  no  doubt  incor
rect.)
  This patient (accord
ing to Mr. Key) left the
hospital in one month,
quite  well.  No report
after that. 
150          RESULTS OF SURGICAL OPERATIONS
              SECT. VII.—CANCER OF  THE UTERUS.

  Perhaps the most common  form of carcinoma of the uterus is
the scirrhous, and next in point of frequency the encephaloid. What
has been called the cauliflower excrescence, by Sir Charles Clark and
others, is  probably  a mere variety of the latter affection, and is, be-
yond question, of rare occurrence.  As to melanosis and colloid, they
have never, so far  as my information  extends, been the subjects of
operation  in the uterus.
  Excision of the uterus for carcinomatous  disease has been very
seldom performed by American and English surgeons.  In Germany
and France, on the contrary, it has been resorted to not unfrequently,
but with a result so discouraging that it has,  of late years, been
almost entirely proscribed by conscientious practitioners.  The ope-
ration is said to have been first performed by Professor Osiander, of
Gottingen, who  has published nine cases of its successful employ-
ment.   Dupuytren,  also, occasionally executed it, and,  it is said,
with almost invariable success.   But its great advocate, unquestion-
ably,  was  Mons. Lisfranc, of Paris, whom Dr. Balbirnie,  in  his
enthusiasm, has  styled the apostle  of excision.  This  surgeon,  so
celebrated in his day, stated, in 1828, in  a paper communicated  to
the Royal Academy of Medicine, that he had performed this opera-
tion, up to that period, on thirty-six individuals, of whom thirty were
then well, while three had  died,  and three were in progress  of
recovery.   One female, operated on some years before, had since
become pregnant, and had recently given birth to twins.*
   Subsequently to this communication, Lisfranc apprised the profes-
sion that he had excised the neck of the uterus, or the entire organ,
ninety-nine times; but in this statement he is contradicted by Mons.
Pauly, who, after a careful  examination of all  the  facts, declares
that he could make out only fifty-three cases.  Of the results of these
fifty-three cases  we have, unfortunately, authentic  information  of
only nineteen.   Of these, only one was permanently benefited;  four
died within twenty-four hours after the operation;  twelve had  an
immediate relapse ;  and in two others, in which the disease was im-
perfectly removed, death happened only the more rapidly, on account
of the interference of the surgeon.f

  * Practical Formulary of the Parisian Hospitals, by F.  S. Ratier, M. D. p. 17.
  f Churchill on the Diseases of Females, p. 191, Phila. 1843. 
                  IN  MALIGNANT DISEASES.               151

  The operation of excision of the neck, or  of the neck and body
of the uterus, is not only generally useless, as it respects a perma-
nent cure, or even considerable temporary benefit; but it is extremely
liable to be followed by immediately fatal consequences, and ought,
therefore, on this account, to be abandoned as  a common proceeding.
The greatest danger to which it leads is  prostration, which is often
so severe as to lead to  speedy dissolution.  Very few survive this
shock when the entire organ is removed.  Another danger is hemor-
rhage.  Out of nine patients  operated on by Lisfranc, under the
observation of Pauly, six suffered from this cause, and of this number
three died within twenty-four hours.  Sometimes death is occasioned
by pelvic phlebitis, or by peritoneal inflammation.  Finally, instances
are mentioned where the difficulties were so great that, in attempting
to excise the affected parts, the operator has opened the  peritoneum
and the urinary bladder.  The former of these accidents  happened
to Lisfranc; the latter, to  Sauter and Roux.
   It was in consequence of the indifferent success  following this ope-
ration, as  a curative agent, and of the great danger attending its
execution, that Dupuytren, Osiander, and other surgeons and obste-
tricians were induced to  discontinue it.  Even Lisfranc rarely resorted
to it in the latter periods of his career.
   A case, in which excision of the neck of this organ was performed,
is mentioned by Professor Atlee, of Philadelphia, in  the  sixteenth
 volume of  the American Journal of the Medical Sciences.   The
 operation was performed  on the  21st  of December, 1846, and the
 woman,  who was  forty-six years  of age, died on the 9th of  May,
 1847, within a few days  after  reaching her  residence at Pittsburg.
 The parts were inspected for the last time on the 24th of April, when
 the wound was found to be perfectly smooth and sound.  The general
 health had  not been good  during  the winter, and  the  system was
 evidently in  a cachectic condition.  It is to  be regretted  that there
 was no examination of the body.
   Professor Eve, of Georgia, on the 16th of April, 1850, performed
 the  daring  operation of  removing the entire uterus, through the
 vazina  for encephaloid  disease, in a  negress,  aged twenty-eight.
 The woman recovered from the immediate effects  of the excision, but
 died at the end  of three months and a week, from a return of the
      1 int   No post-mortem examination was made.  An account of
 Z operation, accompanied by two drawings of the morbid specimen,
 has been published by Professor Meigs, of Philadelphia  m the Ame-
 rican Journal of the Medical Sciences for October,  1850. 
152          RESULTS  OF SURGICAL OPERATIONS
   The following  paragraph, by Professor Meigs, in the paper just
referred  to, has a direct bearing upon the subject  of  this report:
" M. Colombat de l'ls&re informs us that the operation—extirpation
of the uterus in  situ—has been executed by Sauter, by Hoelscher,
twice by Siebold, and thrice by Langenbeck; four times by Blundell;
once byBauner;  once by Lizars; twice by Recamier; once by Du-
bled; twice by Roux, and once  by M. Delpech; while this operation
by  Professor  Eve adds one  integer  to  the whole  number, which
amounts  to twenty operations, in all of which the result was contrary
to  the hopes of the surgeons."
   The subjoined table,  drawn up for this  report by Dr. William  H.
Miller, of this city, gives the  results of operations in twenty-one
cases of  cancer of this organ:— 
Tabic of Twenty-one Cases, showing the Results of Excision of the Neck of the Uterus for Malignant Disease.
                            By William H. Miller, M. D., of Louisville.
	•5 Tem*	Resi-	Cause.	)ura- Symptoms and progress.		Mode	Result.	Structure.	Surgeon.	Authority.	Post-mortem appear-ance.	Time last seen.
I fc I'm	3 & Pera; S •< ment.	dence.		tion.		of ope-						
Z, IS |M		|	|			ration.						
1 1	1 WUn-	Eng- !	J2 y'rs		Slow; discharge puru-	Liga-	Partially	Cauliflower	Ashwell.	Ashwell on Diseases		Died of a relapse 2 years afterwards. Shortly afterwards became pregnant.
2 1	| | known 5 331	and 1 3cot-and		3 y'rs	ent, bloody, and offensive. Slow; discharge watery, bloody and offensive; con-	;ure Exci-sion	successful Successful	excrescence Cancer	Simpson.	of Females, p. 313. Edinburgh Medical Journal, vol. Iv. p.		
					stant hemorrhage.					104.		
3	25	Bo-			Great hardness and ul-	"	"	a	Francesco	Ibid., p. 297.		
4	33	opna Brus-sels	Mental anxiety		ceration of the neck. Lancinating pain in the uterus; fetid excoriating	a		u	Itizzoli. Lisfranc.	Medico-Chirurgical Review, vol. x. p.		One month.
5 1	6 30	France	Heredi-tary	lyear	discharge. Lancinating pains; he-morrhage, nausea, &c.	"	«	«		160. Ibid.		Two months. One month.
6	L 25	"	Following	8 mo's	Lancinating pains; ve-	It	tt	"		Ibid.		
			abortion		getations; cervix tume-							
	1 22	a		Over o year	fied and indurated. Lancinating pains; tu-mefaction, induration,	«	«	ii		Ibid.		Four months.
8 1	1 35	"		5 mo's	and leucorrhoea. Progress rapid; indura-tion and ulceration of	«	"	«		Ibid.		One month.
9 1	12	"	Mental affliction	3i y'rs	womb; lancinating pains. Slow; induration and ulceration; fetid dis-charge ; acute pains.	a	it	"		Ibid.		Two months. ■six weeks.
10 1	1 27			5 y'rs	Great pains; yellow skin; general health bad; irregular menstruation; ulceration and indura-			tt		Ibid.		
11 1	50	Con-stance		6 mo's	tion. -7 Copious hemorrhages; acute pain; numerous hard excrescences on the neck; painful and fun-	"	ii	"	Sauter.	Balbirnie on Dis-eases of the Womb. p. 328.		Died two months afterwards of in-digestion.
12 1	50	Eng-land		9 mo'.	gous ; sanious discharges Ulcerations; hemor-rhages; neck of uterus of cartilaginous hardness.	"	"	"	Blundell.	Ibid.	Fungous degeneration of both ovaries; peri-toneal redness; rectum and colon distended.	Died a year after-wards of a relapse.
 
Table of Excision of the Neck of the Uterus for Medignant Disease—Continued.

	■i		i		Tem-	Resi-	Cause.	Dura-	Symptoms and progress.	Mode Result.		Structure.	Surgeon.	Authority.	Post-mortem appear-	Time last seen.
	|	-^	2	6	pera-	dence.		tion.		of one-					ance.	
13	1	-Z	3	< 50	ment.					ration.						
					Nerv-	France		S mo's	Constant pain following	K.xci- Successful		Cancer	Recamier.	Balbirnie on Dis-		Six months.
					ous				cessation of menses; ul-ceration of a foul fungous	siou				eases of the Womb. p. 333.		
14	1		8	42		a			Large tumour on the neck of the womb; cal-lous, bleeding, soft, and granulated.			Cauliflower excrescence	Duges.	Ileining's Transla-tion of Madame ISoiviu, p. 297.		Died in three months.
15	1		1	30		"		4 mo's	Large tumour on the neck; bleeding and granu-lated.		it		it	Ibid. p. 299.		Return of disease a year afterwards.
16	1		3	30		a			Progress rapid; cervix	Caustic "		a	"	Boivin and Duges,		Died in a month of
									voluminous, indurated,					p. 200.		peritonitis.
									and of a deep red colour.							
17	1			34		"			Cauliflower excrescence, with a sero-sanguineous discharge. Great emaciation; fe-	Knife		u		Ibid. p. 300.		Living four years afterwards.
18	1		1	27		«		1 year		Exci-	a	Cancer	Lisfranc.	Balbirnie on Organ-	l£	Died in five months.
									ver ; yellow skin; uterine	sion				ic Diseases of	■ff	
									discharge of a cancerous					Womb.	f	
									odour.							
19	1		1	54					Has had cancerous symptoms for years: fun-gous growth on the neck, with profuse discharge.				Dupuy-tren.	Ibid.		No return of disease eight years after-wards.
20	1			50		Eng-land		S mo's	Cachectic consistence;	tt	"	tt	Blundell.	London Med. Gaz.	Fundus of bladdei	Died in one year.
									OS uteri ulcerated, and of					August, 182S.	eancerously diseased:	
									a stony hardness; hemor-						death caused by consti-	
									rhages.						pation.	
21	1		C	130		France			Profuse fetid discharge: ulceration and induration of neck; cylindrical fun-goid tumour attached to the womb.	Liga-ture			Kecamier.	Medico-Chirnrgical Review, 1820, p. 200.		Died one month af-terwards.
 
IN MALIGNANT DISEASES.
155
       SECT.  VIII.—CANCER OF THE ANUS AND RECTUM.

  The most common form of cancer of these outlets is the scirrhous;
encephaloid is observed  only  occasionally; and  in  one or two in-
stances they have been known to be the seat of colloid.  Rokitanski*
and Curlingf  allude to the occurrence of epithelial cancer of these
parts; but of this  I have never seen an instance, and the affection
is unquestionably very rare.
  Cancer of the anus and rectum  does not differ, in respect to its
curability by excision, from cancer in other regions of the  body.  In
my own cases, I have invariably declined all interference of the sort,
under the conviction, first, that it  could not possibly result in any
permanent benefit;  and,  secondly, even supposing  that it would be
followed by a prolongation  of life, which, however, it rarely is, the
advantage thus gained would be more than counterbalanced by the
distress and inconvenience occasioned by the loss  of the  sphincter
muscle.   Lisfranc, of Paris, and Dieffenbach, of Berlin, have been,
in modern  times, the warmest advocates  of excision  of  cancerous
tumours of  the anus and rectum.   The former  of these  celebrated
surgeons performed the operation repeatedly, but with what success
cannot be determined, because no reliance is placed by any one  in his
statements.   Dieffenbach^ asserts that he had recourse to  the knife
in not less than thirty cases of this kind.   In one, the disease re-
appeared  within four weeks, and  in some others in three months;
but the larger  proportion continued well  many years  afterwards.
Who will  believe that all these cases were cases of real  cancer, or
even epithelial formations ?  Certainly, no one who knows anything
of these  complaints.  We must, therefore, conclude that Dieffen-
bach was  mistaken in his diagnosis; or, what would be less agree-
able that he has wilfully published what is  untrue.


               SECT. IX.—CANCER OF THE BONES.

  The bones,  as is well known, are liable to malignant  disease in
 arious forms,  especially the encephaloid  and colloid.  In what is

  # Manual of Pathological Anatomy, translated for the Sydenham Society, vol. ii.

P 4- Observations on the Diseases of the Rectum, p. 116, Lond. 1851.
  t Brit, and For. Med.-Chirurg. Review, Oct. 1850. 
156          RESULTS OF  SURGICAL OPERATIONS
denominated osteosarcoma,  the textures characteristic  of  these
two deposits often exist, either alone, or in combination.  The case
which I am about to describe appears to me to have been essentially
of a colloid nature, though upon  this point we have no positive in-
formation.   The case has become memorable in the annals of sur-
gery, not  so much on account  of its  pathological peculiarities, as
by reason of the daring character of the operation performed for its
relief.*
  The  patient, Horace Wheeler, aged twenty-seven, of Randolph,
Vermont, had an osteo-sarcomatous tumour, larger than a hen's egg,
and involving the metacarpal bones of the thumb  and  index finger,
which Professor Mussey removed in  1817.  In  September,  1831,
more than thirteen years afterwards, the arm was amputated at  the
shoulder-joint, the  malady having seized upon the  radius and the
upper half of the humerus, where  it formed  a very large swelling.
The  patient had  suffered excessive pain during the last few years,
the shoulder-joint was very stiff, and the soft structures  in the neigh-
bourhood were much thickened and indurated.   The wound healed
readily, and the parts appeared sound; but, subsequently, several
abscesses formed in the stump, and some months elapsed before  the
cure  was completed.   Five years afterwards, the disease returned in
the scapula and clavicle;  and, in September, 1837, Professor Mussey
performed the daring feat of removing both these  bones in their
entire extent.  The immense wound united by adhesion, and became
consolidated without the formation of a teaspoonful of  pus.  In the
summer of 1852, Professor Mussey heard from  his patient, who sent
him his compliments, informed him that he was perfectly well, and
that  he  intended to visit Ohio this  summer, when he hoped to pay
him his respects.
  The  tumour, in the last operation, contained a  quantity of thick
glue-like substance, enveloped by a mass  of  cartilage, interspersed
with  small osseous deposits.   A part of the clavicle and more than
three-quarters of the body of the scapula, with its spine, acromion,
and  coracoid process, exhibited  a  coarse  spongy texture, with exu-
berant  bony vegetations.   The  appearances were similar  on  the
humerus, and on the metacarpal bone of the thumb.
  Mr.  Stanley, of London, who has published the best  work on  the
diseases of the bones in the English language,  thinks that encepha-

  * Amer. Journ. Med. Scien. vol. 21, p. 390, 1837; Transactions Amer. Med. Asso-
ciation, vol. iii. p. 331, 1850 
IN MALIGNANT DISEASES.
157
loid of the osseous tissues is probably always at first local, and that
it  continues  so until the solids  and fluids become affected by the
absorption of the morbid matter, when  secondary tumours form in
other parts of the body.   " If,  therefore," he  remarks,*  " the ori-
ginal encephaloid tumour is removed  before the blood has become
poisoned, the disease will not return; but, if the morbid matters have
already entered the circulation,  it will be reproduced."  In conso-
nance with these views, Mr. Stanley advises that the limb upon which
the tumour is situated should be  amputated as early as  possible, due
regard  being had, of course, to  the condition  of  the neighbouring
structures and the system at large, for where these are involved all
interference  of the kind is improper.   I imagine,  not so much from
personal experience as from a  careful  study of many of the recorded
cases of malignant disease of  the bones, that the morbid action will,
in the  generality of instances, return more  or less promptly after
removal of  the  affected structures, no matter how early and how
effectually this may be done.   If I mistake not, Mr. Stanley's own
cases, those,  for  example, adduced  under  the  name  of osteoid
tumours, which  he singularly enough separates from encephaloid,
strikingly confirm the truth of this position.  That the disease  here
is as much an affection of the  constitution as  when it occurs in the
 soft parts, is  shown by the fact that it is almost always attended with
 contamination of the adjacent lymphatic ganglions, and involvement
 of the internal organs.

                     GENERAL  CONCLUSIONS.

   From  the facts  and statements which have now been  presented,
 embracing the opinions of many of the most intelligent, experienced,
 and distinguished practitioners in different ages and in different parts
 of the  world, the following  conclusions may be legitimately de-
 duced:—
   First. That cancerous  affections, particularly those of the mam-
 mary gland,  have always, with  a few rare  exceptions, been re-
 garded by practitioners as incurable by the knife and escharotics.
 This opinion, commencing  with  Hippocrates, the father of medicine,
 has  prevailed from the earliest  records of the profession to the pre-
   ent moment.  Nature never  cures a  disease of this kind; nor  can
 this be effected by any medicine  or internal remedies known to the
 profession.
          * A Treatise on Diseases of the Bones, p. 151, Phila. ed. 1S49. 
158          RESULTS  OF SURGICAL OPERATIONS
  Second.  That  excision,  however early and thoroughly executed,
is nearly always,  in genuine cancer, followed by a relapse at a period
varying from  a few weeks to several months from the time of the
operation.
  Third.  That nearly all  practitioners,  from the time  of Hippo-
crates  to  the  present day, have been  and are still averse to any
operation for the  removal of  cancerous  tumours after  the establish-
ment of ulceration, rapid growth, firm adhesions,  organic change in
the skin, lymphatic invasion, the cancerous dyscrasy, or serious con-
stitutional derangement; on the  ground that, if had recourse to under
these circumstances, the malady almost inevitably recurs in a very
short time, and frequently destroys the patient more rapidly than
when it is permitted to pursue its own course.
  Fourth.  That in all cases of  acute carcinoma, or, in other words,
in all cases of this disease attended with very rapid development and
great bulk of the tumour, extirpation is improper and unjustifiable,
inasmuch  as it will  only tend  to expedite  the fatal  result, which,
under such circumstances, always takes  place in a very short time.
  Fifth. That all operations performed for the removal of encepha-
loid  cancer and its  different varieties,  are  more certainly  followed
by rapid relapse than operations performed  upon  scirrhous  or hard
cancer.
  Sixth. That in nearly all operations for cancerous diseases hitherto
reported, the history has been imperfectly presented, being  deficient
in the details which are  necessary  to a complete  and thorough
understanding of  the subject in each  case.   This remark is  par-
ticularly true  in reference to  the  diagnosis  of  the  malady,  the
minute examination of the  morbid structure, and the history of the
case after the operation, as  to  the  period of relapse, the time and
nature of  the patient's  death,  and  the result of the post-mortem
examination.
  Seventh. That  cancerous affections of the lip and skin, now usually
described  under  the name  of  cancroid diseases, are  less liable
to relapse  after  extirpation  than genuine  cancerous  maladies,  or
those which are characterized by the existence of the true cancer-
cell and cancer-juice.
  Eighth.  That  although  practitioners have  always been aware,
from the earliest professional records, of the great liability of cancer
to relapse after extirpation, a great majority of them have always
been, and still are, in favour of operation in the  early stage of the
disease, especially in  schirrus, before the tumour  has  made much 
                    IN MALIGNANT  DISEASES.               159

 Progress, or before there is any disease of the lymphatic ganglions
 or evidence of the cancerous cachexy.                      S    '
 wfT^That. T^ CaSGS °f tUm°UrS' specially tumours  of the
 breast and testicle, supposed to be cancerous, are in reality not can-
 cerous, but of a benign character, and, consequently, readily curable
 by ablation, whether effected by the knife or by escharotics.  It is to
 this circumstance that we must ascribe the astonishing success which
 is said to have attended the practice of Hill, of Scotland, Nooth, of
 England, and Flajani, of  Italy.
   Tenth.  That all operators insist upon the most thorough excision
 possible; removing not merely the diseased mass, but also a portion
 of the surrounding  and  apparently  healthy tissues, as well as  all
 enlarged and indurated ganglions.
   Eleventh. That the practice  has  always prevailed, and still ob-
 tains, to save, if possible, a sufficient amount of healthy integument
 to cover the wound, and to unite, if possible, the wound  by the first
 intention;  on the ground that  these  precautions will tend much to
 retard, if not to prevent, a recurrence of the disease.
   Twelfth. That much stress  is laid by writers upon  a properly
 regulated diet, and attention to the bowels and secretions after ope-
 ration, as means of retarding and preventing relapse.
   Thirteenth.  That there is no' remedy, medicine, or  method of
 treatment which has the power, so far  as we are enabled  to judge of
 its virtues,  of preventing the reproduction of the morbid action after
 operation,  no  matter how early  or how thoroughly it may be per-
 formed.
   Fourteenth. That life has occasionally been prolonged, and even
 saved, by operation after relapse, as in some of the remarkable cases
 mentioned in a previous part of this report;  but that, as a general
 rule, such  a procedure is  as incompetent  to effect a  permanent cure
 as a first extirpation.
   The following points may be considered as of an unsettled charac-
 ter;  at all  events, opinion  respecting them is much  divided, and
 farther observation is necessary before  they can be positively deter-
 mined,  either affirmatively or negatively.
  First. Excision is of doubtful propriety in all cases in which the
 disease is of hereditary origin, or where it occurs in several members
of the same family.
  Second.  It is doubtful whether an operation should be  performed
when  the patient is very young and the disease is of rapid growth. 
160          RESULTS OF SURGICAL OPERATIONS
 There is reason to believe that surgical interference, in such a case,
 will only expedite the fatal issue, which is generally inevitable.
   Third.  It is problematical whether an operation should  be  per-
 formed when the disease is  attended by suppression of the  menses,
 or by great irregularity of this  discharge.
   Fourth. Not a few surgeons regard a resort to the knife as of
 questionable efficacy when there is a quickened state of  the pulse,
 occasioned by the local irritation.
   Fifth. There appears to  be  no general  agreement  among  sur-
 geons  as to whether  extirpation  is  proper when there are two or
 more coexistent and accessible cancerous tumours.
   Sixth. It is supposed, but the fact is not  established, that  ex-
 cision of carcinomatous tumours only tends to hasten the patient's
 death.
   Seventh.  It is doubtful whether,  as has been  asserted by different
 surgeons, the prospect of a permanent cure is greater, all other things
 being equal, after an operation on an old cancer, than after an ope-
 ration on a cancer of recent  standing.
   Eighth.  It  has been  stated  by writers  of great respectability,
 among others by Dr. Macfarlane, of Glasgow, that, in robust women
 of sanguine temperament, the reappearance of cancerous disease, and
 its subsequent progress, are more rapid after operation than in nerv-
 ous or lymphatic persons;  an assumption demanding verification.
   Ninth. It requires to be  proved whether excision ought to be per-
 formed in the ulcerated stage of malignant disease, as a  means  of
 prolonging life  and of procuring comparative relief  from suffering.
   In bringing  my labours to a close, I feel conscious that I have
 added nothing whatever to our previous information of malignant
 diseases.  Nor, in truth, could  this have been reasonably expected.
 My sole aim has been to  sum up our knowledge upon the subject; to
 construct, as it were, a mirror which should reflect the practice and
 opinions  of our predecessors and  contemporaries, and thus serve as
 a guide to future travellers in the same path.  In a word, my object
 has been to show, not only what  has been done, but what remains  to
be done.  The facts which I have collected, if useful at all, are so
rather in a negative than in a positive point of view. Our knowledge
of the results of surgical operations in malignant affections  is in a
state of transition, which has much to hope from the future, but can
gain little, if anything, from the past. What the microscope and animal
chemistry, guided by the hand  of  modern science,  may do for the
subject, it would perhaps, be premature to predict; already they have 
IN MALIGNANT  DISEASES.
161
rendered the cause  essential  service, and  it would certainly be un-
philosophical to suppose that they are incapable of  affording farther
light.
  Finally, in drawing up this report, I have rarely appealed to my
own experience, believing that, even if it were fully exposed, it could
add nothing of real value to the general stock of our knowledge upon
a subject respecting which so  much has been written by others.  In
point of number, indeed, my  own cases could not be put in competi-
tion with the extensive  scale of facts brought forward by some of the
surgeons, the results of whose labours it has been my duty to bring
before the Association.  I have little, indeed, I  might  say, no  con-
fidence in  any operation for malignant diseases, except  the cancroid
varieties;  and I have for years past, as Professor of Surgery in the
University of Louisville, deemed  it my duty to discourage a resort
to  the  knife  in  all cases of  the kind, especially in scirrhus and en-
cephaloid  of the mammary glands, ample  experience having satisfied
me  of  the utter futility of such  an expedient, however  early and
efficiently employed.   In  cutaneous cancer, on  the other hand, my
rule has  always been  to  operate, provided the  disorder has not ad-
vanced so far as to preclude the possibility of removing the whole of
the morbid growth; and provided, also, that there is no evidence of
constitutional infection.  To this rule I shall rigidly adhere, unless
my own experience, or the experience of  others, shall  show me the
impropriety of it, when I shall most cheerfully abandon it.
11 
 

ON THE
KESULTS  OF  SURGICAL OPERATIONS
MALIGNANT  DISEASES,
K*J'>
BY
S. D. GKOSS, M.D.
^j,
PRESENTED TO THE AMERICAN MEDICAL ASSOCIATION,

      AT ITS SESSION OF MAY, 1853.
'f
     PHILADELPHIA:
T. K. AND P. G. COLLINS, PRINTERS.
         1853. 
 
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