A Practical Essay on Cancer; being the Substance of Observations to which the Annual Prize for 1808 was adjudged by the Royal College of Surgeons of London. By CHRISTOPHER TURNER JOHNSON, Surgeon, Exeter; Member of the Royal College of Surgeons of London, and of the Royal Medical Society of Edinburgh. 8vo. pp. 126. London, 1810.

THAT Cancer has long been esteemed one of the opprobria medicorum must be admitted, and every attempt to investigate its history and to improve its treatment, deserves encouragement; it is upon these grounds, therefore, we presume, the Royal College of Surgeons have bestowed their annual medal for this performance. How far the author has been successful in effecting either one or the other of these objects, or whether he has, in the least degree, added to our previous knowledge of the subject, it is our duty to ascertain, taking it for granted that nothing superior to the present Essay was offered to the notice of the Royal College on this occasion,

"The term Cancer," the author informs us, in the first paragraph of his book, is employed "to denote a particular connected train or series of morbid phenomena, occurring in the human body." We can inform the author, that the terms gout, smallpox, fever, and the name of every disease incident to the human body, are so employed; but surely it becomes necessary to enumerate, at least, some of the phenomena occurring in this particu lar train, to constitute the definition of any one disease; and yet, that the author means this paragraph to stand for a definition, we conclude, because we can find no other. In appropriating terms, indeed to the various stages of the disease (whatever it be) he is treating of, he thinks it requisite to ascertain the extent of signification in which they should be applied to the different stages re、 spectively, and which he does as follow:

"The words schirrhus, carcinoma, and cancer, have been variously employed, in extent of signification, by almost every different writer; and from this circumstance, it becomes necessary to explain the meaning which is intended to be attached to them in the subsequent parts of this Essay. Cancer, as a general term, will be used to express every gradation in the disease, from its commencement to its termination; but, as it may sometimes be desirable to speak in a more limited sense, I shall, for this purpose, and in compliance with custom, distinguish two principal stages of the disease: the scirrhous and carcinomatous."

Here the word cancer being used as a general term to express every gradation in the disease, remains equally undefined as to what particular train of phenomena it is applied, and we are equally in the dark as to the precise disease the author means to treat of. We were the more surprised at this want of precision in the author, because he observes, Under the title of cancer, it has been but too frequent a practice, to associate together an almost indefinite number of morbid alterations of structure, without pre

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viously inquiring whether they possessed any such settled agreement of character, as would, with strict propriety, allow of individual cases of disease being included under a general definition. This has most unquestionably been one very fertile source of error; and, while speaking of it, I may, therefore, advert to the necessity which there exists in every philosophical investigation, of setting out with a clear and distinct conception of the particular object of research; for, in what case, let it be asked, ought this mode of reasoning to be more forcibly insisted on, than where our enquiries relate to the nature and cure of disease? These, it deserves well to be recollected, are matters which involve considerations of much more than speculative importance."

To conduct a philosophical investigation to any useful purpose, requires a closeness of reasoning, and an accuracy of expression which our author has not displayed in this Essay; and the obstacles which, in the following quotation, he laments as impeding the progress of our knowledge, he has by no means contributed to re

move.

"The promiscuous and unguarded use of the term cancer, has tended more, perhaps, than any other single cause to retard the progress of our know ledge concerning those affections which really deserve the appellation. No one ever pretended that we should be warranted in applying the same epithet, indiscriminately, to every different case of disease, merely on account of its proving untractable and yet, with respect to the subject of the present inquiry, this very thing seems to have been done, without the least scruple or hesitation. It is sufficiently obvious, however, that in order to constitute the identity of any two cases of disease, something more must be required than such vague and very distant features of resemblance."

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Were we inclined to cavil, we might observe, that the circumstance of a disease proving generally untractable, is sufficient to justify us in bestowing, "without the least scruple or hesitation," a pretty harsh epithet upon it; but no epithet can amount to a definition of a disease, it does not even constitute its name, being never more than an adjunct to distinguish some good or bad quality belonging to it; we agree with the author that no features of resemblance can constitute the identity of any two cases.

"The author's aim, is to collect and concentrate into one point of view, all the valuable information that is to be found scattered throughout the works of preceding writers on Cancer;" but he informs us, that "there are yet, comparatively, but few cases of cancer upon record, which have not lost more or less of their sterling value by want of due attention to some of the particulars which have been here mentioned." To whom this want of due attention, whereby these cases have lost their sterling value, is to be attributed, we do not discern; we ourselves should rather have judged these cases to have been originally deficient in sterling value, from this cause; but we submit to our author, who thinks other

wise, for that he has correctly expressed himself we cannot doubt, since in the very next paragraph he says, "it is by giving precision to our language, and by this alone, that we can ever hope to obviate those frivolous and unmeaning disputes, which turning upon the different interpretation of particular words and phrases, infest medical science, in common with almost every other branch of useful knowledge." We have before observed, how desirable it is, that in every case, correct definitions should be given of the diseases on which authors mean to treat; we presume Mr. J. means to express the same opinion in the following paragraph, although, we confess, we do not clearly understand what is meant by establishing a more intimate connexion between the word cancer, and the particular phenomena of which it should be expressive.

"An attempt is still worth making to establish a more intimate connexion than has hitherto subsisted, between the word cancer and the particular phenomena of which it should be expressive. This would require that its precise extent of signification should be clearly and accurately defined: which, though it might have the effect of excluding from the catalogue many diseases vulgarly called cancerous, must yet be a principal means of promoting careful and accurate observation. In prosecution of this plan, it is likely that we should in time become better qualified to mark the nicer distinctions, and shades of difference, which separate this complaint from every other."

We have dwelt thus long upon this part of our author's book, because we considered it our duty, particularly, to examine a publication ushered into the world under the auspices of the Royal College, in order to ascertain what claims the author had upon the attention of the public, independent of collegiate sanction. The intrinsic merits of the work do not consist in a superior phi losophical arrangement of the various parts of the subject, nor in a more luminous view of the facts already known; but as the result even of individual experience is always valuable, when related in language correct enough to be easily understood, we shall proceed to detail the substance of our author's information on the subject before us.

The chapter on the History of Cancer is divided into several sections, detailing, respectively, the progress of the symptoms in the various parts of the body which may be affected with the dis ease, as the breast, the uterus, the testicle, &c. In the term Cancer, the author includes two stages, the schirrhus and carcino, matous; scirrhus, however, may subsist independent of any cane cerous affection, either local or constitutional, nor do we think that the author has used the term cancer in the general accepta tion, since all nosologists have arranged scirrhus and cancer as two separate affections, the former of which may exist in glandular parts as an effect of simple inflammation; but admitting that scirrhus may also be the consequence of cancerous affection, how is it to be distinguished from what may be called simple scirrhus, or

what

what the author calls "the enlargement of the glands from simple irritation." Speaking of cancer of the testicle, the Author says, "the disease begins here as in all other glandular organs, by a partial induration." Now as partial induration may, we conceive, arise in an organ independent of cancerous affection, how shall we distinguish when it is, or is not, cancer? Here, we think, the author has failed in giving us any diagnostic signs whatever; the same thing may be said of "that enlargement which is so frequently seen to arise in scrofulous constitutions."

"In every case of this kind, in which there may be a doubt, it will at any rate be proper to examine the state of the lymphatic glands in other parts of the body; and more particularly in the neck and axilla of the opposite side. The information which may, in this way, be obtained, taken in combination with the general history and appearance of the patient, will materially assist us in ascertaining the nature of the case. The peculiar kind of shooting pain, which is generally attendant on scirrhous structure, may also serve to facilitate the distinction.

"It has been said, that such of the lymphatic glands as are situated in the immediate vicinity of the diseased part, may undergo a degree of enlaregment from simple irritation. This, however, never seems to happen except where some accidental inflam❤ mation is present in the early stages of a scirrhus: besides which, it further admits of being distinguished, by yielding to those means which are calculated to lessen and subdue inflammation in ordinary cases."

To found any diagnosis upon the effect of treatment is unphilosophical, to denominate that cancer which is untractable, and to infer a similar appearance not to be so, because it gives way to certain means, is not sound reasoning; and yet, that the author depends for his diagnosis rather upon the event, than the actual state of such affections appears probable, when he says, "External disease, appearing under the form of either tumour or sore, will sometimes, from accidental causes, assume an appearance of malignancy which it does not in reality possess: and, viewed in this state, there is reason to believe that various other morbid affections have at different times been mistaken for cancer, and treated accordingly,"

How we are to distinguish the actual degree of malignancy but by the external appearances, we are at a loss to tell; the author says, "in proportion to the rapidity of the progress of any individual case, so is its degree of malignancy." This we conceive to be a fallacious criterion, for accidental circumstances may accélerate or retard the progress of cancer, without at all affecting its malignancy, so far as is distinguishable by any symptom; and to assume rapidity of progress as a criterion, is, at least, begging the question. The history of cancer of the breast, of the uterus, and of the testicle, affords nothing very new, as the progress of the disease in each of these parts is well known.

The following description of Cutaneous Cancer, and the marks of distinction between it and Lupus, as described by Dr. Willan, deserve attention,

"Cutaneous cancer, at its commencement, usually appears un der the form of a small præternatural enlargement, or elevation of the skin. In feeling and consistence it is sometimes so hard as to approach to the nature of horn; while, on other occasions, it will bear a much nearer resemblance to a common wart. There are, besides these, some few instances, in which it would look to be no more than a little discoloured pimple.

"Whatever form the disease may at first assume, there will invariably be found to take place, a degree of surrounding hardness seldom or ever to be met with, under other circumstances. Some degree of shooting pain is likewise, from time to time, experienced in the part. In many of these cases, ulceration seems to be materially accelerated by the accidental irritation of the patient's fingers, which are very often, though unconsciously, employed in the vicinity of the disease. Sometimes, however, a sort of scale is generated, so as to form a compleat covering of defence to the little tumour, and this will be artificially removed, and again renewed several times in succession, before ulceration is fairly established. This phænomenon is seen most remarkably in that affection of the scrotum peculiar to chimney sweepers.

"When the part has once arrived at a state of ulceration, it soon puts on those characters of malignancy, which have occasioned it to be classed as a species of cancer. The surface of the sore possesses, indeed, the common appearances of carcinomatous ulceration: and there is also a discharge from it, of sanious, op otherwise ill-conditioned, matter."

"The particular situations which cutaneons cancer is most frequently observed to occupy, are the lower lip, the angles of the eyes, and the alæ nasi; but some of these parts are also liable to another affection, which, though, in its nature, very widely remote from cancer, still bears a good deal of resemblance to it, in appearance. What I here allude to is a disease which has been described by Dr. Willan, under the generic name of Lupus. It begins under the form of numerous small brown pustules, which soon go on to a state of ulceration. The parts upon which it commonly first seizes, are the forehead, the eyebrows, ale nasi, and upper lip. When this disease is situated in the nose, it is not the soft parts alone that suffer from its destructive effects; these will, in the course of time, be extended so as to affect both the cartilages and turbinated or spongy bones.

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"The ulcer of the soft parts extends slowly, having a dusky, copper-coloured disk, and attended likewise by a good deal of surrounding hardness.

"This disease may generally be distinguished from caucer by a careful attention to the following circumstances. Lupus is chiefly seen to occur in young people; while, on the contrary, the cutaneous cancer is scarcely ever observed, except in those who are considerably advanced in life. Cancer, again, hardly ever attacks the upper lip, though it is perhaps one of the most frequent seats

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