in the inter-muscular areolar tissue, and, extends inwards, involving the other textures. In the progress of the disease, the muscular fibres become pale, degenerate, and lose their distinctive characters, in that of the morbid growth; the calibre of the bowel is diminished by contraction, and by the projection of tubercles and nodules into it. Ulceration ensues, which may extend till perforation of the bowel takes place. Abscess is sometimes formed in the ischio-rectal fossa, leading to the formation of fistula; abscess may also occur in the cellular tissue of the pelvis, and the matter discharge itself by openings situated above the crest of the ilium, over the sacrum, and about the buttocks and upper part of the thighs; should an internal opening with the intestine coexist, these channels will constitute stercoraceous fistulæ. The pelvic bones may also become affected by caries, or otherwise involved in the disease.

The rectum in some cases is involved in cancerous disease, which has its origin in adjoining structures; it is frequently implicated when the disease has commenced in the uterus, or in the upper part of the recto-vaginal septum, and then, by the process of ulceration, a communication may be formed between the rectum and vagina; in the male the bladder is 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.

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

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

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.

Malignant discase of the rectum is more frequent in females than in males, and in the former it is usually developed at the period of the cessation of the menses. Those about the meridian of life, or a little past it, are mostly liable to these 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, often attributed to functional * Op. cit., p. 292.

derangement only, but arises from the morbid growth projecting into and narrowing the capacity of the bowel, and also annihilating the function and power of contraction. 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 fœtid; 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; the whole of the digestive organs are 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 acute peritonitis.

In the commencement, unless the disease is within reach of the finger, and occurs as hardened tubercles or irregular fungoid growths, the diagnosis of the disease is not easy, and requires a close and accurate consideration of all the symptoms, and a familiarity with the various phases and phenomena of malignant disease, to arrive at a just conception; but in the advanced stage the excessively severe shooting pain, the fœtid puriform discharge, the rapid progress of the affection, and the peculiar unhealthy aspect of the countenance, lead to a correct conclusion. Yet the latter appearance is not invariably present, as was illustrated in a man aged fifty, who applied at the Blenheim Dispensary, in 1852, affected with fungoid disease, the masses of which nearly filled the pelvis; his countenance remained clear, and his general health was not much disturbed for a considerable time he lost blood at stool, and a copious hæmorrhage followed any examination, even when conducted with the greatest care and gentleness.

In the treatment of this disease all our efforts will be unavailing in effecting a cure, but by well directed means we shall be able to mitigate the sufferings, and even to