CHAPTER VIII.

THE ARM AND HAND.

This

THE selection of these parts for the development of epithelial cancer is more curious than rare. I have seen several instances in both sexes, and many are recorded in the reports of hospital practice. peculiar localization is doubtless due to some injury, for I have generally observed it amongst laundresses and agricultural labourers; both occupations involving the exposure of the hands and arms to irritating substances. Occasionally its origin has been attributed to the picking of a wart. The induration which accompanies the ulcer, its slow growth, and the little impression made upon it by any remedial application, are generally sufficient to distinguish epithelioma from any other ulcer in these parts. Boils and carbuncles have none of the brawny hardness of this form of cancer, but I have seen a low form of phlegmonous inflammation on the back of the hand mistaken for cancer, and treated with caustics, even by a hospital surgeon of considerable repute in London. A few notes of this case may be instructive.

William S., aged sixty-nine, a publican, came under my care September 1, 1864. There was a large deep sloughing ulcer on the dorsum of the right hand,

exposing the extensor muscles and tendons. The surrounding integument was thickened, and had a duskyred hue. He had been two months under treatment, and the sloughing ulcer was extending. The treatment had been caustics and linseed poultices. I ordered him a carrot poultice three times a day, and a tonic, with generous diet. September 8: ulcer clean now, with healthy granulations. September 15: ulcer remarkably diminished and quite clean. September 22 : ulcer quite healed. Is well in every respect. The cleansing and stimulating qualities of the carrot are perhaps scarcely sufficiently appreciated in all foul indolent ulcers.

Epithelial cancer of the arm or hand generally takes place in advanced life, is slow of growth, does not give much pain, and only affects the general health when it is accompanied with suppuration. If it is observed early, before it has attained attachments to the periosteum, it may be wise to excise the part only; but if it cannot be freely moved over the bone, amputation is the most conservative treatment. In 1852 I amputated the fore-arm of an agricultural labourer from Essex, who was sixty-eight years of age, on account of an epithelial cancer of the hand, which began two years previously as a warty scale upon the thumb. When he came under my care I found the thumb and fore-finger separating by ulceration, and the disease extending across the whole of the back of the hand. The patient was very weak and had a red glazed tongue, with a disposition to diarrhoea. He was evidently dying from exhaustion produced by the suppuration. Under chloroform I removed this source of vital drainage, and

notwithstanding an attack of phlebites he recovered and went home seven weeks after the operation with the stump quite healed, and his general health reestablished. A microscopic examination of the hand exhibited epithelial scales and cells having nuclei and nucleoli in various irregular shapes. The old man came to town to see me a month after his return, and exhibited a ruddy agricultural aspect, quite refreshing to look at. Although there was occasional pain in the stump, this man resumed his labour, and for five years

afterwards I continued to hear from time to time that he was well, and had no return of the disease. I have had other cases, not so satisfactory as this; and others who have refused operation, and have died certainly much earlier and in greater distress than those who have been operated on, regretting that they had not yielded in time to the advice which would have prolonged their days. There are six cases given in Mr. Jonathan Hutchinson's clinical report on Epithelial Cancer, but, as usual, without any history subsequent to the recovery from the operation, except in one instance that was a case under Mr. Paget's care.

A man aged 62: had been accustomed to set stoves. Cancer of the back of the hand began eighteen months before as a painful wart. Amputation through the fore-arm was performed in July 1852, and the patient died two years and a half after the amputation of bronchitis. There was, however, at the time an open cancer in his axilla. Three of the six cases were submitted to amputation. One under Mr. Teale, at Leeds, suffered excision and removal of the first and second fingers, and in the other two cases the ulcer only was

excised. We cannot gather from these cases any rule of action, owing to the absence of any history of the results of the operations; but I think it will be generally allowed, that the rules for excision or amputation given above are well founded.

I would add, however, the observation, that whereas excision cannot be done too quickly after the disease is recognized, amputation need not be performed until the patient is beginning to fail in general health, as the glands are not readily implicated. I have an old man now under my care who has had an ulcer of this kind for five years, and it still remains in a quiescent state. I do not counsel any trials with caustic to remove this ulcer, because I know how worse than useless they are ; but oxide of zinc and glycerine, liquor plumbi and glycerine, the ceratum calaminæ, carbonate of lime lotion, and other soothing sedative applications, may be employed with good effect in retarding the progress of the disease; whilst in all cases constitutional support is of the greatest value. Cod-liver oil, hydrochloric acid, iron, bark, whatever may be found most suitable to the individual, should be employed, together with a liberal diet, and free exposure to a bracing atmosphere.

CHAPTER IX.

THE EYE.

THIS important organ is unfortunately the seat of cancer in its most malignant form, and at all ages. Children of two and three years old have encephaloid cancer of the eye, which runs a rapid course, and in old people the same disease with the addition of a melanotic deposit affects this organ.

The early diagnosis of cancer of the eye is beset with some difficulties, for the first appearance of a tubercular deposit on the retina has the same yellow hue which is afforded by the cancerous affection, and in both it takes a lobulated form, which is overspread with enlarged vessels ramifying in various directions. As the growth increases the pupil dilates, and the eyeball itself begins to be more prominent, although not apparently altered; and there is little, if any, pain. Gradually the lens becomes opaque, thus obscuring the view of the morbid growth. All the textures now increase in vascularity, the whole globe is enlarged, the cornea becomes dim, and the sclerotic, instead of being tense and glistening, is soft and pulpy, and bulges at one or more points. At this stage pain becomes a more prominent symptom, until the globe bursts, emitting its fluid contents, and usually the lens also; and