Two Histories of Internal Cancers, and of What Appeared upon Dissection, by William Burton, M. D.

II. Two Histories of Internal Cancers, and of what appeared upon Dissection, by William Burton, M.D. I. Read May 13. Windsor, May 22. 1734. Bartholomew Collins, a Labourer in the King's Works at Windsor, of low Stature, pale Complexion, slender and active, aged about 36 Years, temperate in his manner of Living, had, for some Years, been afflicted at different times with wandering arthritic, colic, and nephritic Pains, none of which were periodical or constant. During this Term, when in best Health, he was usually costive, and his Urine, as soon as made, deposited a calculous Sediment. In March 1733. he received a violent Blow by a ponderous and obtuse Instrument on his Loins, together with the Spine of the Os Innominatum, towards the Left Side, which disabled him for that Day; on the next, the Pain abating, he continued so well for Six Months after, as not even to recollect this Accident, till about a Month before his Death, although he was often asked by the Physician, Whether that Part had ever suffered a Contusion. In January following, he complained of an excruciating Pain, extending from the aforesaid Spine to the Spurious Ribs on the Left Side, which sometimes attacked also the Intestines; whence he became continually restless, especially in the Night, and, tossing the Bedcloaths off, frequently lay naked. He could not now lie upon his Back or Left, viz. the affected Side, but lay always on his Right Side, leaning on his Right Elbow. In April 1734, his Left Knee, from a Contraction of the Muscles elevating it, was always drawn up towards the Abdomen, insomuch that he could not stand upright. His Left Testicle, formerly less than the Right, was now become scirrhous, and increased to double the Magnitude of this, and the Left Spermatic Vessels felt like a knotty Chord. A sort of Hectic Fever attended him, the Exacerbation of which, as well as of his Pains, was generally about Noon, and Six in the Evening.—He had no Sleep of Nights without a Paregoric.—Though his Appetite failed him, he had no Propensity to vomit, nor complained of Thirst. His Respiration and Urine were not amiss.—His Pains were always exasperated by the Use of heating Medicines; and whenever the Pain seized the Intestines, terebinthinate Clysters increased them, whereas emollient and refrigerating ones mitigated them; by the Use of which he had daily one or two Stools.—The Fæces were of a middling Consistence, lightly tinged with Bile.—The Blood frequently taken away by V. S. in small Quantities, had always a thick, tough, sify Buff-like pleuritic Coat; and at first, from each several Bleeding, he found Relief. January 4. 1733-4. The Apothecary first administered to him, for the Colic, Elect. Lenitiv. & Pulv. Diasen. Ol. Junip. and emollient Clysters. Three Days after, Pains seizing his Left Side, and the Sphincter Vesicae, they were removed by repeated bleedings, and Decoët. Hord. & Lap. Prunel. and Syr. Althææ. On the 12th, he complained of a Heat Heat about the *Regio Pubis*, with Costiveness; but by the Use of *Sal. Mirab. Glaub. Lap. Prunel. Manna*, emollient Decoctions with *Sp. Nitr. d.* & *Elect. Lenitiv. pro re nata*, continued tolerably easy till the 24th, when the erratic Pains returning, and not yielding to the aforesaid Apozems, on the 26th the Physician first consulted gave him *Sperm. Cet. Sal. C. C.* & *pulv. e Chel.* and *Sp. C. C.* but these not availing, the *Lap. Prunel.* was sometimes interposed, and a *Calomel* Bolus, taken at Night, was worked off by a Sena Potion next Day: This Method, and afterwards Powders of *Lap. Prunel.* and *Cinnab. Antim.* taken in Honcy, mitigated those Pains. But from *February 3.* to *April 4.* sometimes nephritic Pains, intermitting Fever, pleuritic Pains, and Strangury, inordinately afflicted him, notwithstanding the Use, according to the said Indications, of carminative, terebinthinate and saponaceous Clysters, Purges, *Sal. Absinth.* Draughts, repeated bleedings, Vesicatories, the Powders and Electuary above-mentioned, Opiates, *Cort. Peruv.* in an Electuary, and infused in Wine, *Lac Sulph.* with Asses Milk, *Cinnab. Antim. Millep. Gum Guaiac.* and *Pulv. e Chel.* with *Vinum Milleped.* and *Sp. Nitr. d.* On *March 20th,* *Calomel.* Gr. v. were given for Four Nights successively, and afterwards purged off with a Sena Potion, and then continued again till the 28th, when he took another Potion.—Paregorics were used now-and-then at Night, and *Ung. Opodeldoc* was applied to the *Testicle.* *April 4th,* I first attended him in Consultation, when he complained of an intolerable Pain, upon any Pressure about the Region of the Left Kidney; whereupon a maturating Cataplasm was applied in the Day-time, and a Plaister at Night. Emulsions, Whey, and such-like, were the chief Internals he used till April 8th, when crude Mercury was recommended to him, of which he took an Ounce Night and Morning, which gave so much Relief as to encourage the Continuance of that Medicine only to the 17th, when the Pains returning, he was bled once in Two or Three Days, to Four or Five Ounces, and treated with the subacid, cooling Regimen, and Paregorics, till April 29th, when he first mentioned a scirrhouss Tumour, as big as a Hen’s Egg, situate on the Left Mastoid Muscle of the Neck. Upon comparing this with the Testicle, (neither of which Tumours were in the least diminished after Applications for that Purpose) it was conjectured, that either the Pancreas or Mesenteric Glands were cancerated. An Emetic of Oxym. Scillit. farinaceous Decoctions with Nitre, crude Sal Armoniac, Oxym. Simp. and Diacod. were of little or no Effect.—Afterwards continuing the Use of Electuaries of Conf. Ros. r. Elect. Lenitiv. Bals. Locatell. Æthiop. Min. Sperm. Cet. Ol. Amygd. d. and the same with Mercur. Alcalizat. he became more and more emaciated, till May 21st, the Day of his Death. It was remarkable, that every new Medicine, except it was very heating, afforded some Relief for Two or Three Days. May 22d, On removing the Integuments of the Abdomen, the Musculi Recti appeared livid.—The Omentum was destitute of Fat.—The Intestine contiguous to the Left Os Innominatum was tinged with Green.—Nothing besides appeared morbid in the Viscera Viscera in Situ at first View.—The Situation of the Pylorus seemed lower than usual. The Colour or Texture of the Liver were not remarkably preternatural. The Spleen was of the largest Size, and adhered in its hinder Part so strongly to the Peritoneum, that it could not be separated without Laceration.—Whereupon there remained in the Place of Adhesion a thick, callous, and almost horny Membrane, as big as an Half-crown.—The Pancreas was very small, and seemed composed of small Scirrhi.—The Left Kidney was twice as big as the Right, or as its own natural Magnitude: Its Substance about the Pelvis was corroded by a semipurulent cancerous Sarcies, that was in part collected between the Surface of the Kidney and its containing Bag. The internal Structure of it was not much amiss: But the Fomes Morbi, the most singular and surprising Phænomenon in this Subject, was a Number of large conglobate, steatomatous, cancerated Glands, reaching from the Receptaculum Chyli to the lowest Vertebrae of the Loins, so connected together as to represent a Pancreas affixed to the Vertebrae of the Loins, and upper anterior Part of the Left Psoas Muscle: It was Four times as large as his Pancreas, and as big as the Right or sound Kidney.—The Aorta descendens pervaded the Middle of this preternatural Substance Lengthways.—From this Mass, as a Fountain, flowed that cancerous Sarcies, which had made its Way to the Left Kidney, and also corroded the superior carncous Part of the Left Psoas major, and Iliacus internus, so that one might easily rend their gangrened Flesh like rotten Linen.—Some of this green Ichor collected near the Os In- Innominate had laid the Spine of it quite bare. The Left spermatic Vessels were knotty, tumefied, and livid—The mesenteric Glands were scirrhouss. The descending Trunk of the Aorta was smaller than usual; and, dividing it, we extracted a small Polypus.—The Examination of the other Cavities was not permitted. II. January 11. 1735-6. Thomas Trinder, a Taylor, living at Windsor, in his 29th Year, was of a pale Complexion, with red Hair, of a middle Stature, and thin Habit, addicted to smoking from Morning to Night, and now-and-then to hard drinking. Eight Years before his Death, he was thrown in Wrestling, so as to pitch the Small of his Back upon the Corner of a Chair, by which at first he was much hurt in that Part; but upon the Abatement of his Pain, he became from that time subject to Fits of the Colic, in which he said his Bowels seemed to be drawn to his Back-bone, and usually received Ease by binding his Waist as tight as he could.—He had also frequent recourse to Geneva and such Liquors for Relief, but seldom found any, till a Swelling, as big as a Hen’s Egg, appeared like a Rupture in his Right Groin. These Fits were not of above 24 Hours Duration, but the inguinal Tumor lasted Two or Three Days. He was often afflicted with Stitches under his Left Breast, which were removed by Bleeding. But in the Middle of November 1735, his Colic became so violent, that he could not lie in his Bed, nor sleep without Opiates.—November 21. I found him him in the Use of some carminative Pills sent by an Apothecary. He had frequent Reachings to vomit, and was very costive. His Pains seemed confined to the intestinal Region, and were most acute in the Evening, continuing to harass him till Five or Six in the Morning. His Pulse beat seldom under an Hundred in a Minute, at Night generally above. He was not very hot, nor thirsty. His Urine at this Time was rather defective in Quantity, than amiss in respect of Colour or Separation.—His Tongue was foul towards the Root, but not very white.—Upon his taking Ipecacuan. 3fs. and after its Operation a Sal. Absinth. Draught, with Syr. and Tinct. Rhabarb. a 3ij, and the plentiful Use of Infus. Sem. Lini, Barley-water, Broths, and Clysters of Whey, Oil, and Honey, his Reachings ceased, and the Pains descended from the Epigastrium to the Hypogastrium. On November 24th, a Potion of Tinct. Rhabarb. cum Vino 3ij. Elix. pp. Helm. 3j. Sal. Absinth. 3fs. and Two purgative Clysters, one of which had Terebinth 3fs cum Vitel. Ov. not procuring a Stool, he took a Bolus of Calomel 3fs & Camphor. gr. xij. h.s. and the next Day his Pains continued, though he had several Dejections from the Cathartic. Bleeding was omitted hitherto, because he had 3x. of Blood taken away a Week before this Paroxysm; but now, upon losing so much Blood more, he found immediate Relief. His Blood was very sify. After this, his Disorder resembled a Nephritic one, his chief Complaint being of Pain about the Region of the Kidneys, and along the Descent of the Ureters. From November 26th, upon the Use of an oily Linctus and Manna, Sal. Absinth. Draughts and and Nitre, Clysters as well as Drinks of Whey and Honey, with Paregorics, and repeated Bleeding, the Pain, removing from the Loins, fixed itself at the Os Pubis, and in the Thighs, November 29. but by the Use of Emulsions with Gum Arabic and Nitre, the Pain about the Pubis abated, and mostly afflicted the Left Thigh and Hip. From this Time he generally sat up in his Bed, leaning forward to the Left, and for the most part cross-legged, finding himself easiest in this Posture. He could not lie any time on his Right Side.—The Quantity, Colour, and Sediment of his Urine, were much the same now as when he was in Health.—It was made without the Pain, which, soon after the nephritic Symptoms commenced, he complained of at the Root of the Penis. And now his Disorder resembled the Lumbago and Sciatica, affecting the Left Side mostly: Whereupon, December 2d, he was put in the Use of a diuretic and aperient Electuary, with Terebinthinate Clysters.—To this Time he had very few Stools without Clysters, and those generally very small and fetid. December 5th, the Fever and Pain increasing, a cooling aperient Apozem, with a paregoric Draught pro re nata, were continued till December 9th, when examining the Thigh where the Pain now afflicted him most, I found some small Scirrhi in the Groin, which were sensible enough to the Touch, though not to the Sight; and from that Time, apprehending him of a scrophulous Habit, prescribed as follows: Ἡ Myrrh. Milleped. Suc. Glycyrrhiz. Terebinth. Venet. Pil. Matth. a 3i. Bals. Gilead. 3iis Diacod. q. s. f. Pilulae N° xx. Capiat ii tertiis horis cum Sero Lactis, which giving Relief, were re- repeated, only exchanging *Pil. Matth. gr. viij.* for *Ol. Anif. gtt v.* and continued to December 12th, when his Pains returned violently, and he coughed up clotted Matter, not unlike the *Parenchyma* of the Lungs abraded, with a little Blood. His Breath became fetid, his Respiration troubled, and he complained of Thirst. He used oily paregoric Draughts to the 15th, about which Time he was seized with so violent a pleuritic Pain, in the Middle of the Night, that it was thought he must have expired, had not about 3x of Blood been taken away immediately, upon which the Pain soon removed from the Side, and attacked him there but for a few Minutes afterwards. The Blood continued as fizy as ever. In the Evenings, when his Pains were most vehement, he had been sometimes delirious. December 18th, he first told me of a Tumor he had discovered near the Navel, since I saw him on the 15th. It appeared not as he sat, but when laid on his Back, there was a Protuberance bigger than a Turkey's Egg, Four Fingers Breadth on the Left Side of the Navel, extending Two above it, and Four below it. By its Situation, Resistance to Pressure, and the Unevenness that from under the Skin was communicated to the Touch, its disappearing when he was in an erect Posture, and its not being diminished by discutient Fomentations, it was judged to be a scirrhous Tumor, which had long existed there unobserved by the Patient, till it increased too much to be longer undiscovered.—The *Emplast. de Ran. & cum Mercur.* was applied outwardly; and concluding there was an internal Cancer, I was encouraged, from the preceding Case, to order him *Hydrargyr.* every Morning.—Whereupon there was such a Remission of his Pains, that during almost a Fortnight, he got more Rest without Opiates than before with them; insomuch that being greatly revived, and regaining some Appetite, he got down Stairs Two or Three times. Thinking the Plaister increased his Pain, Indigo blue Linen was applied in its room. The Mercury came away by Stool, and he had now one almost every Day, and sometimes twice a Day, without a Clyster.—His chief Drink was Milk and warm Water.—His grand Complaint now was of a most troublesome Cardialgia, especially when he lay down, which was somewhat mitigated by Powders of Cret. Britan. cum pauxillo Sal. Absinth. From the first Use of the Mercury he seemed on the mending hand, till after about 12 Days, when omitting it for a few Days, he relapsed into his former or a worse Condition; and though he was somewhat easier on the Repetition of it, the good Effects lasted not long.—He drooped daily from the 4th of January, and on the 13th died, emaciated and almost exanguis. Upon Dissection, nothing preternatural appeared in the Integuments, abdominal Muscles, or Peritoneum immediately under them.—But under all these, where the Protuberance had been observed, and immediately under the Omentum, (which was destitute of Fat, and its lower Part was mortified) there came in View an anomalous Substance in Situ, seemingly as big as a very large Potatoe; which, when the circumambient Viscera were removed, was found to be a scirrhouss, fungous, cancerated Excrecence, rooted, as it were, to the Left Side of the Ver- Vertebræ, quite from the Diaphragm down to the Pelvis, of a monstrous Bulk, occupying near one half of the Abdomen, lying like a Tortoise with its Head towards the Pelvis, and its Back to the Umbilicus. It was in the upper Part covered by and firmly cohered with the Colon, which in the whole Contiguity was black and mortified. It was strongly attached to the Peritoneum on the Left Side of the Lumbal Vertebrae, having displaced the Left Kidney, and brought it forwards to the Left Side of the Navel, so that it came in View as soon as the Omentum was removed. It likewise removed the Aorta descendens, the Left Emulgent, and Mesenteric Vessels, quite out of their natural Situation; all of which were found pervading the Centre, nearly, of this Excrescence, and smaller than natural.—It adhered to the Kidney strongly where the emulgent Vessels enter it, and it had detruded most of the small Guts into the Pelvis.—Nothing was preternatural in the Stomach or Spleen, excepting that the latter, as well as the Left Kidney, seemed paler than usual, and this Kidney also more flaccid: The Gall-bladder was shrunk to the Size of a Nutmeg, and empty.—The Liver had a preternatural Lobule, as big as a Hazel-nut, adhering to it by a small Pedicle. But otherwise all these Viscera, as well as the Right Kidney, Bladder, &c. discovered nothing morbid. This cancerated Excrescence could not be eradicated without Laceration, and upon the Removal of it, Two or Three large Trunks of Nerves appeared naked, passing over the Iliacus internus to the Thigh, which had been compressed by this Tumor. The Weight of this Excrescence was $\text{fiv} + \frac{3}{4}\text{xiv}$; and allowing for what remained upon Laceration, and the Effusion upon cutting into it, it doubtless exceeded $\text{fiv}$. Upon Bisection, it appeared to the Depth of half an Inch from its Surface black and gangrened, and, below that, it was all spongy, with Cavities as large as those of an Honeycomb; and from it had issued a cancerous Sanies, draining to the Pelvis. Upon opening the Thorax, the Right Lobe of the Lungs was full of scirrhous cancerated Tubercles, from whence a Sanies had flowed betwixt it and the Pleura: The Left Lobe was much smaller than the Right, firmly attached to the Pleura and Mediastinum, and inseparable without Dilaceration.—It had some Tubercles also. The Heart appeared sound, but a large Polypus was taken out of its Right Ventricle, at the Orifice of the Arteria Pulmonalis. Another Case occurred to me cotemporary with the first of these, and so like to both of them in the antecedent Cause and Symptoms, that, could I have obtained Leave to inspect the Corpse, I am persuaded some such immediate Cause would have discovered itself.—Crude Mercury was the only Medicine in this Case also, that palliated for about Ten Days successively. But to what Purpose so particular a Relation of Cases confessedly incurable? It is replied, That in unsuccessful Cases an accurate Diagnostic tends not a little to the Reputation of the Physician, and his Science, although thereupon he pronounces the Case incurable by all the known Methods of regular Practitioners—Especially as this Case is very likely to be mistaken at first for an Arthritic Disorder, or a Nephritic one, either from Ulcer, Calculus, or both, or for an Iliac Passion. The Diagnostics therefore of a Cancer within the Abdomen, deduced from the preceding Histories, seem to be as follows: A naturally slender Habit of Body, accompanied with some scrophulous or scirrhouss Tumor, together with a pale Complexion, and costive Disposition: If such an one, at an Age above Twenty, has received a violent Contusion on the Loins, and, neglecting all Remedies, is some time afterwards attacked with excessive Pains, afflicting now the Colon, then the urinary Passages, Spine of the Os Innominatum, and Pubes, at various times, always increased by all Internals or Externals, by which the Heat of the Body is increased, especially Terebinthinate Clysters; but mitigated by some Singularity of Posture, in which the Patient constantly abides; if these be attended with an Hectic Fever, without the usual Degree of Heat in the Skin, of Whiteness or Dryness of Tongue, or Complaint of Thirst, and also without Cough, high-coloured Urine, or vitiated Respiration; if accompanied likewise with an Affection of the Spermatic Vessels, of the Thighs, and frequent pleuritic Pains; the Blood always abounding with tough Size; if Opiates soon lose their Effect, and only (as all other new Remedies not heating) seem to give Relief for Two or Three Days; if Cathartics take Place, and by frequent Repetition do not produce a colliquative Diarrhoea, and the most palliative Remedies are nitrous Salts and Mercurial; may it not be concluded with much Probability, that such a Case is owing to some such Cause? May it not be pronounced an internal Cancer? III. Ener-