IV. Ulcerated Carcinoma of the Rectum. The vicinity and sympathy between the rectum and uterus, will render it sometimes difficult to determine which part is affected, without an accurate enquiry and examination. The uterus is more liable to cancer than the rectum-and this should be borne in mind. In the early stage of carcinoma recti there is a mucous discharge, which gradually becomes purulent, and this appearance may lead us to suspect fistula, but examination puts the question to rest.

"If the finger of the practioner be carried into the rectum, it will be girt by a constriction of considerable thickness, through which it cannot be passed; and if any attempt is made to surmount the difficulty by violence, the patient will suffer excruciating pain, and a discharge of blood will be the consequence of such a rude enquiry." F. 203.

It is useless to be too anxious to ascertain the extent of the disease. A small carcinomatous thickening of the intestinal canal is as fatal as that of a larger portion. A carci noma affecting not more than a quarter of an inch of the rectum may, by obstructing the passage of the fæces, cause a distension of the whole colon, and fatal inflammation, the consequence of that distension-a carcinoma of great extent can do no more.

In common ulceration the part is absorbed-in carcinomatous, new matter is deposited, as the old is removed, and thus the thickening and destructive processes proceed simultaneously. It is evident that the rectum cannot be kept at rest; and if the constipation be not viewed in relation to its proper cause, and the patient be exposed to the action of frequent purgatives, the symptoms will be aggravated by the means employed to alleviate them. The following melancholy picture is not overcharged, as we have too often had opportunities of verifying its correctness.

"All the symptoms which attend the first stage of this disease will be found to exist in a greater degree in the second. The darting pain will be increased both in frequency and in violence; the action of the heart will be greatly and permanently accelerated; the functions of the stomach will become more and more impaired ; vomiting will be almost constantly present; temporary relief will be found only in opium; and permanent rest only in the grave. In the progress of the ulceration, blood-vessels will be exposed which will pour out, according to their size, a larger or a smaller quantity of blood and happy would it be for the patient if such hemorrhage should prove fatal; but such an event is hardly to be expected; and, unless in parts more abundantly supplied with blood than the rectum, such an occurrence is seldom met with." 207.

As nearly the same treatment is necessary in this case as in ulcerated carcinoma of the uterus, we shall proceed at once to the latter subject.

V. Ulcerated Carcinoma Uteri. The carcinomatous lumour of the cervix uteri has been treated of in our author's former volume, to which we must refer the reader. A woman may live many years under such circumstances, provided she submits to proper rules; but sometimes our best efforts fail, and the ulcerative process takes place, on a more or less extended surface. In the latter case, the disease will be tedious-in the former, the fatal termination will be rapid. It ought to be borne in mind, however, that the ulceration goes on more rapidly at first, than in the progress of the disease-owing probably to weakened power of absorption in the latter period, keeping a ratio with the general decline of the powers of life.

"Thus a number of instances will be found, in which the patient will exist in a state of extreme weakness during many weeks or even months, contrary to the expectations of the medical attendant. Spontaneous bleedings from the ulcerated surface, producing more sudden debility, will have the same effect in retarding the progress of the disorder." 212.

In an early stage of the ulceration, it is not unusual for the patient to complain of a puffy and enlarged state of the external organs-owing to the increased action of the neighbouring vessels. A great degree of itching is another symptorn, and sometimes erysipelas. The cuticle often desquamates-trifling oozing ensues, which, drying on the surface, forms furfuraceous scales, a new source of irritation, often exending to the groins and insides of the thighs. The discharge, at first ichorous, and afterwards purulent, is by no means comparable in quantity with that which is met with in some other diseases of those organs-and sometimes even diminishes as the disease advances, in consequence of the diminished quantity of blood in circulation.

If the bladder and rectum have not suffered in the early stage, they seldom escape now-not only from sympathy, but from the disease extending itself to these, in common with the adjacent parts. Such a degree of thickening takes place sometimes in the meatus urinarius as to impede the passage of the urine, and require the catheter-shortly after which the urine will spontaneously escape, not through its urinary passage, but through a communication between the neck of the bladder and vagina.

In a very few cases a communication between the rectum

and vagina takes place, and from that moment no fæces pass by the anus-the external parts forming the channel through which urine, fæces, and pus are discharged. The stench now becomes intolerable, and the hips of the patient lying immersed in the excreted matters, the soft parts inflame, and sloughing takes place! It is needless to say that the wear and tear of the constitution, under such circumstances, is great. The patient becomes a skeleton, and dies under a complication of the most terrible phenomena which it is the lot of hapless mortality to endure! The situation of a woman labouring under carcinoma uteri is infinitely more pitiable than that of one with cancer in the breast; for not only are the symptoms more numerous and insufferable, but she has not the good fortune to be cut off, in the progress of the disease, by accidental occurrences. In mammary carcinoma the patient is usually destroyed by hydrothoraxbut no such blessing is afforded to the subject of carcinoma uteri; the sufferer being compelled to endure till her frame is exhausted by pain, by vomiting, by want of sleep, by discharge, by an offensive atmosphere, or by gangrene of the integuments!

VI. Treatment. Though carcinomatous ulceration does not obey the laws by which common inflammation is governed, it is nevertheless controlled, in some measure, by those means which subdue common inflammation.

"Whenever a patient, labouring under carcinoma of the uterus, has placed herself under the constant care of a physician or surgeon, it will be necessary that he should watch with attention the changes which take place in her constitution. If he should find the circulation becoming accelerated, the skin more than usually hot, flabbiness of the integuments, softness and shrinking of the muscles in different parts of the body, he may presume that some important change has taken place in the diseased organ. If, together with these symptoms, the lancinating pain has been rendered more acute; if the sympathies between the uterus and the adjacent parts, or between that organ and the stomach, have been more than usually called forth; or if, lastly, the mucous discharge has assumed a puriform character, there can be little doubt that a breach of surface has taken place, and that the complaint has acquired its most frightful and distressing character." 219.

If the patient possess a vigorous constitution, we are hardly authorized to omit general bleeding; but this will seldom be requisite, as local bleedings can be repeated as often as necessary. The quantity to be abstracted in this way may vary from six to twelve ounces at a time, and the glasses shouldbe applied just above the fissure between the nates. If it be

judged proper to bleed from the lower part of the abdomen, leeches should be scattered above the pubes, from one groin to the other. In the progress of the complaint leeches may be applied to the labia, or even within the vestibulum, "by means of which more relief is sometimes obtained than by their application to the pubis." Local blood-letting should be employed once in three weeks or a month-provided the patient be not weakened by it, or exhausted by pain or discharge. Spontaneous hæmorrhage, to the extent of syncope, not unfrequently arrests for some time the progress of the disease. Even in the latter stages, when the loss of blood might appear unwarrantable, it may still be proper to recommend it; since it is well known that carcinoma uteri, in its ulcerative stage, involves all the neighbouring parts in a state of inflammation and irritation. For instance, when the rectum is attacked, there is tenesmus, great heat in that part, increased distress in voiding the fæces, exquisite tenderness of the gut, if the finger be carried into it. So in like manner, if the disease proceeds to the bladder, shivering usually comes on, succeeded by great pain, and strangury. If the disease makes its way, which is not very common, into the abdomen, symptoms of peritoneal inflammation will, of course, make their appearance. All these circumstances, therefore, call for the loss of blood, even in a late period of the disease.

The management of the discharge is a matter of great importance; for there is reason to believe that the spreading of carcinomatous ulcerations may be greatly retarded by the absorption or removal of the ichorous fluid secreted by them.

"Of all the modes of applying water to sores at the upper part of the vagina, none is so effectual as the use of the hip-bath; in the employment of which, the water is brought into contact with the sore without any risk of injuring the latter. By these means, the object of maintaining cleanliness is not only obtained, but a soothing application is made to an irritable surface; the careful injection of warm water into the vagina, by a syringe, or the agitation of the water by the hand, will render it more likely to remove any portions of coagulating lymph or thickened matter which may adhere to the inside of the vagina. The heat of the water employed should depend upon the feelings of the patient in some measure; but, generally speaking, it may vary from about 86° to 94°. Where the rient is too weak to bear the exertion of being placed in a hip-bath, her hips may be brought over the edge of the bed, and warm water may be carefully injected into the vagina by a female syringe. The quantity of the discharge is frequently increased by the means abovementioned, but the comfort which the patient will derive from it will abundantly compensate her for any debility which may be produced by the remedy; and excruciating attacks of pain are some

pa

times rendered very sufferable by a frequent recurrence to it. Strong decoction of carrots, sometimes used for the same purpose, has the happiest effects. Warm water may also be made the vehicle for a variety of sedative applications, which are found by experience to tranquillize all irritable sores; and, in some, to expedite the healing process. Amongst the different applications for this purpose, the extractum conii, or extractum hyoscyami, may be mentioned, either of which may be employed in the proportion of about three or four drachms to a pint of water. Solutions of opium, or of extract of poppy, may also be used; of the former, two drachms; of the latter, half an ounce, may be dissolved in each pint of water. Starch, or mucilage of quince-seed, form good menstrua for these applications; their adhesive property enabling them to cling to surfaces to which they are applied. Three or four ounces of either of these fluids, impregnated with sedative substances, may be thrown into the rectum in those cases where relief is not obtained by their application to the vagina; but when opium is used for this purpose, the practitioner should be very careful to watch over its effects, as it has sometimes happened that unpleasant consequences have arisen from the application of this drug to the rectum, such as vomiting, syncope, cold extremities, and irregularity of the circulation. The action of the absorbents of the rectum is, in all probability, in these cases, increased by the inflammatory process which exists in the vicinity; besides which, the action of the rectum itself is temporarily taken off, so that the enema will probably be retained during a considerable length of time. Plasters and liniments, into the composition of which opium enters largely, will sometimes be found serviceable in allaying pain, and are useful auxiliaries in a disease in which all the resources of the practitioner may be required to diminish the sufferings of the patient." 229.

A dilute mixture of acetic or nitric acid in water, forms a soothing application to an irritable part, as acidi acetici 3ss. aquæ distillatæ oj. m. fiat injectio. Or, acidi nitrici gutt. x. aquæ distillatæ oj. m. ft. injectio. Some liquor plumbi acetatis may be added to either of the above. If the discharge become so profuse as to cause debility, astringent injections must be employed: as decoct. cort. granati oj. sulphatis aluminis ss. m. ft. injectio. Or, half a drachm of sulphate of zinc, fifteen ounces of water, and an ounce of tincture of kino, make a useful injection. If hæmorrhage occur, and the patient be in great pain at the time, it may be right not to restrain it hastily, unless the patient's strength has been previously much exhausted. When it is desirable to restrain the flow of blood, the foregoing injections may suffice; or ten grains of argenti nitras to a pint of distilled water.

As to internal remedies, pain being the symptom most complained of by the patient, the sedative class of medi