the patient having for some time felt an uneasiness in defæcation, begins to observe some blood in the stools. Cancer being rarely suspected, he takes sulphur, and confection of pepper, and cholagogues, but to no useful purpose; and at last a digital examination of the bowel is made, when it is found either that the tube is blocked by an exuberant growth of an irregular form, or that the finger passes into an ulcer with raised and indurated edges; or, as has been already observed, there is a hard mass protruding from the verge of the anus, pear-shaped like a pile, but much harder, and having, unlike the hæmorrhoid, an indurated base extending up the gut. Cancer assumes the encephaloid form in this situation in persons of weak health, and especially in those who have a tubercular diathesis. It often begins as an epithelial growth, which soon fungates, and becomes a very large vascular tumour protruding through the anal sphincter.

The purely surgical treatment of either of these cases is by no means satisfactory. Even when the parts can be apparently entirely excised or ligatured, experience shows that the return of the disease is very rapid, and with few exceptions the recurrence is marked by greater malignancy.

In the female a fistulous opening between the rectum and vagina is not an uncommon result in the later stages of cancer of the rectum. The indurated condition of the parts will show at once that those ingenious operations which are so successful in the ordinary rectovaginal fistula, and do so much credit to the surgical ability of the present time, cannot be of any avail here; simply because there is no reparative power in the

tissue which would form the seat of the operation. In the male we more rarely see a fistulous communication established between the rectum and the bladder, and for the same reason, any operative interference is equally out of question here. As in all other operations for the removal of cancer, when such a proceeding is contemplated, it must be possible to excise the whole of the diseased tissue, or we do mischief instead of good to our patient. Surgeons in general practice have larger opportunities of observing the early stages of disease, than those who are consulted only when the disease is pronounced; and it is to these gentlemen we must look for discovering and diagnosing the nature of the affection, at a time when it admits of excision. doubt many valuable lives may be prolonged for a considerable period, by removing an epithelial cancer from the rectum before it has extended beyond the safe reach of the knife.

No

Encephaloid disease of the rectum very frequently dates its commencement from some operation for piles. It grows to a very large size, and is a source of very great misery to the patient. We have, as is usual in this form of cancer, frequent hæmorrhages, which are necessarily encouraged and aggravated by the painful act of defecation. A good nurse will obviate much of this difficulty by a free injection of cold water night and morning. Although the return of this growth after any operative interference is generally quick, it is justifiable in some instances to advise the removal, in order that the patient may enjoy even a short interval of repose. If it be possible to put a ligature round the base of the tumour, that is the most eligible mode of

proceeding, because it is unattended with any hæmorrhage; and perhaps even the écraseur may be used in such a case. If the base of the tumour be too considerable to admit of either of these methods, it may be attacked by the permanganate of potash, or the chloride of zinc, provided it be possible to limit the action of these caustics to the tumour only. As a local application to epithelial ulcers within the rectum, I have found nothing afford so much relief as an injection containing a drachm of sulphate of copper to a pint of water. I have on several occasions been able to send persons about their usual avocations, after having occupied their beds for mouths, by prescribing for them this lotion ; accompanied of course with the tonic treatment, and generous diet, requisite in all cases of cancer. In later stages of this complaint, when it becomes necessary to assuage pain by opiates, it will be found that the suppository is not well borne. Its introduction is attended with pain, and its presence is a source of discomfort. The point of a small glass tube which is attached to an elastic bottle may always be introduced without any inconvenience, and by this means a teaspoonful of liquid holding the requisite amount of opium or morphia in solution may be injected, and will act efficiently; whilst a larger quantity of fluid would be returned, before it had performed the work it was intended to do.

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CHAPTER XI.

INTERNAL ORGANS.

In order to give a complete account of the differential diagnosis of cancer in its attacks upon the viscera, and other internal structures of the human body, it would be necessary to write a treatise on most of the diseases to which these parts are liable. Besides the standard works of Watson and Copland, in which will be found ample instructions for the diagnosis and treatment of these disorders, there are special works upon the diseases affecting the different organs, by physicians of distinction and repute, which will necessarily be consulted in all questions of doubt or difficulty. Dr. Budd on the Liver, Dr. Brinton on the Stomach, give full details of the symptoms which characterise the progress of cancer in these organs; and quite recently my colleague, Dr. Cockle, has published a monogram on Intrathoracic Cancer; whilst Dr. Mackenzie Bacon has done the same service for Primary Cancer of the Brain.

The uterus has engaged the attention of a host of able writers, but I know of no work whose pages may be more advantageously consulted on this matter than the chapter on malignant disease in the comprehensive work of Dr. David Davis, the former distinguished Professor of Midwifery in the University of London.

That cancer does arise primarily in these organs, and in fact in every part of the body, is sufficiently demonstrated by post-mortem results. But except in the case of the uterus, the liver, and the stomach, it is a rare event; and is perhaps in the majority of cases only suspected during life. Dr. Fuller has recorded a case of primary cancer of the heart, which was not diagnosed during life.

Dr. Peacock, the learned President of the Pathological Society, very recently exhibited specimens to illustrate the forms of carcinomatous deposit in the heart, and it will be seen that there are no symptoms of sufficient distinctness to enable the physician to diagnose this affection.

The first set of specimens were removed from the body of a man, aged 19, a patient of Dr. Peacock's at the Victoria Park Hospital for Diseases of the Chest. He was first taken with symptoms of disorder of the liver and digestive organs, to which succeeded dyspnoea, cough, and expectoration and signs of consolidation on the left side of the chest. The heart was slightly displaced to the right side, the pulse was quick and feeble, and there was oedema of the trunk and extremities. He survived for about nine months. The lungs contained minute masses of deposit, which to the naked eye closely resembled tubercle, but proved on microscopic examination to be carcinomatous. The bronchial glands also were extensively cancerous, and the heart was entirely enveloped in a thick medullary deposit, which pressed upon the large vessels at the base and on the auricles. There were also deposits in the liver, spleen, and mesenteric glands, and the aggregate plates