*

liable to be involved, or the disease may originate in that viscus, and implicate the rectum secondarily. When the bladder is the primary seat of the disease, it usually appears in the form of medullary cancer. Mr. Busk exhibited a preparation at a meeting of the Pathological Society, in 1846, taken from a boy who died of acute peritonitis. He had a tight stricture of the rectum, three or four inches from the anus: it was accompanied by ulceration of the mucous membrane, and was produced by a large deposit of medullary sarcoma external to the muscular coat of the intestine. In the greater number of cases, unless they come under our observation from the commencement, we are unable to trace the disease to the tissue or organ in which it originated, in consequence of its extending, and so thoroughly pervading the whole of the surrounding structures.

The extent to which the intestine is affected varies with the character of the disease and its duration : carcinoma may occupy the whole or greater part of the circumference, and extend from one to six or eight inches in a longitudinal direction. Medullary and colloid cancer more generally implicate only a portion of the circumference of the bowel, but its cavity will be greatly reduced by the projection inwards of large masses of the morbid structure.

*Pathological Transactions,' vol. i., p. 67.

We meet with malignant disease of the rectum occurring concurrently with cancerous affections of the mamma, stomach, pylorus, and other organs, and it is very generally found as a secondary deposit in the lumbar and mesenteric glands, and in the liver.

Cruveilhier thinks cancer of the rectum, in whatever form it may appear, is mostly a local disease; but the majority of pathologists consider that malignant disease occurring in any part of the body, if ever local, is only so at a very early stage, that the constitution speedily becomes tainted, and a cachectic and malignant diathesis established: in practice, we find, when a cancerous part has been removed by operation, in the greater number of instances, it returns either in the cicatrix or other parts of the body.

In April, 1855, I removed the right breast of a lady affected with cancer: the disease was circumscribed; the skin so slightly implicated that it escaped the observation of one surgeon who saw her; the glands of the axilla were not affected, and her general health apparently could not be better. But she died about four years after the operation of cancer of the liver. I could recite many similar cases occurring in my own practice and that of other surgeons.

Malignant disease of the rectum is much more

frequent than is generally supposed, and often escapes recognition till an advanced stage of its existence, the symptoms being attributed to one or other of the affections concurring with cancer. I have seen many cases where the patient was presumed to be suffering from fistula, hæmorrhoids, dysentery, stricture, constipation, &c., and a useless plan of treatment pursued whilst the vital powers had gradually declined under the insidious advances of a fatal disease. There is a greater tendency to cancer in females than in males, and in them is frequently developed about the time of the cessation of the menstrual function. The meridian of life, in both sexes, is the period most obnoxious to cancerous affections; but no age is exempt: encephaloid disease is more likely to attack the young than carcinoma. Bushe saw a case of the former in a boy of twelve years, and Mr. Busk's patient, previously referred to, was sixteen years of age.

*

Whatever may be the character of the disease, whether carcinomatous, encephaloid, or colloid, it makes considerable progress, in the majority of cases, before giving rise to any severe or prominent symptoms. Constipation is one of the early effects, and often attributed to functional derangement only, but arises from the morbid growth projecting into and * Op. cit., p. 292.

Fis

narrowing the capacity of the bowel, and also annihilating the function and power of contraction. tula in ano is often met with as a complication. Hæmorrhoidal excrescences, internal and external, are frequent concomitants, resulting from obstruction to the circulation by the cancerous mass: in some cases a muco-sanguineous discharge, more or less profuse, may be all that engages the patient's attention; but sooner or later a dull aching and fixed pain in the sacral region, violent tenesmus, weight and bearing down, especially after defecation, severe shooting and lancinating pains extending to the loins, hips, and down the thighs, are experienced. The stools are passed with difficulty and pain, are scanty and frequent, and attended with bleeding or a puriform sanies, which is often excessively foetid: in fungoid disease considerable hæmorrhage occurs from time to time. In most instances the stools are compressed and figured, or passed in small pellets, as in simple stricture, or diarrhoea may be present. From contiguity or implication severe vesical irritation is induced, and the patient is tormented by a constant desire to micturate in the female the uterus and vagina are frequently affected. Last year I saw, in consultation, a young lady, a patient of Dr. Barnes, who had cancer of the anterior and left walls of the rectum, which were extensively ulcerated: the cancer

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also affected the posterior wall of the vagina, the mucous membrane of which was not ulcerated, yet she complained of more pain in this part than in the rectum. I saw a similar case in consultation with Dr. Ridsdale. The whole of the digestive organs become deranged, causing flatulent distension of the stomach and intestines, and acute pains in the abdomen as the disease advances, hiccough, eructations, nausea, and vomiting are present; the appetite fails, emaciation and loss of strength ensue, the countenance assumes the peculiar leaden hue indicative of malignant disease, anasarca and hectic supervene, and under continuous suffering the vital powers succumb. Sometimes obstruction takes place, and the patient dies with the symptoms of internal strangulation; or ulceration having extended up the bowel, rupture takes place during an expulsive effort, and fatal peritonitis occurs. This happened to Dr., an eminent physician residing in Lincolnshire, who sent for me in July, 1859, the day before he died. His bowels had not been moved for eight days previously to my seeing him I passed a small O'Beirne's tube and injected some thin warm gruel, which had the effect of bringing away large quantities of fæcal matter; this was repeated several times. I left him on the following morning to return to town: subsequently he had several free evacuations: late in the afternoon, while

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