sibility afforded by the manipulation of these growths. Not only in the breast, where it is most manifest; but in the lip, in the tongue, in the uterus, in the testicle, on the hand or foot, or any part of the body accessible to the touch, this intense induration of tissue is, I may say, never absent.

The probability of confounding fibrous tumour of the uterus with cancer is very slight, owing to the different behaviour of the two diseases, although from experience I find that it is not quite impossible, in even experienced hands. I saw a lady lately who had been operated on for a supposed fibrous tumour in this situation, and the result showed that the disease was cancerous. It may be, in this instance, as I have seen in a case that I related sometime since to the Harveian Society, that the two diseases were coincident in the same person. In its attacks upon the uterus, cancer rarely commences in the fundus or body, whilst these are the parts especially selected by the fibrous tumour. When cancer forsakes its usual point of attack; namely, the os and cervix, and involves the body of this organ, it may be distinguished from fibrous tumour by the sense conveyed to the finger, when introduced per rectum, of a hard swelling of the whole uterus; whilst a fibrous tumour will almost invariably convey the idea of a hard round body, thrown out from a somewhat more pliant and yielding base. The hardness of a Hunterian chancre is certainly very nearly as absolute as is that of cancer, but the circumstances of the case are generally so different that one would imagine the diagnosis of these two diseases could not be confounded. I have, however, had occasion to observe cases where

there has been a halting between two opinions in this matter. In a young woman I saw at the Royal Free Hospital, it was a matter of some doubt whether a round ulcer, with an indurated base on the lower lip, was cancer or primary syphilis. Diligent search over the surface of the body, and digital examination of the occipital, submaxillary, and cervical glands, soon decided the question. Some characteristic secondary spots were beginning to show themselves on the chest, and the submaxillary and cervical glands were somewhat enlarged and painful. In a case of cancer of the penis which was for a long time under my observation, the surgeon first consulted had considered that he had to do with syphilis, and treated it both locally and generally with mercury. The patient, a gentleman of about seventy, came to me, believing that he had syphilis. He had been suffering from an indurated sore on the prepuce for four months, and the treatment employed had had no beneficial effect. The sore was very hard and sloughy, certainly much resembling what one has seen in younger men, but beyond that the whole penis was unnaturally indurated. I had no difficulty in at once deciding that it was a case of cancer, and the death of the poor old gentleman two years afterwards confirmed my diagnosis. This case will be found recorded in a subsequent page.

The next great characteristic feature of cancer is pain.

CHAPTER III.

PAIN.

THE formation of pus in any of the tissues, but more especially in bone, is attended with the most acute suffering. Sharp and frequent lancinating pains, preventing sleep, destroying the appetite, and wasting the powers of life, are the accompaniments of an abscess, Most of us have endured this torture in the simple form of a whitlow. The pain of cancer, often endured for years, is only paralleled by the severe but happily temporary suffering I have just referred to. This stabbing pain is certainly very characteristic. It is not constant, or the patient could not live; but comes at uncertain intervals, and is so startling as well as severe, that it makes the sufferer bound from her chair or couch, not infrequently with a sharp cry of anguish. It is as though a dagger had been thrust into the tumour. This peculiar pain is remarked in whatever part of the body the cancer may be situated. The breast and the uterus are the parts in which it is most distinct and most distressing; but it is to be observed in cancer of the rectum, of the tongue, of the lip, of the eye, and of all the internal organs. The diagnostic value of this peculiar pain is very great, inasmuch as it does not

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accompany the tumours which may be confounded with cancer, except in two instances presently to be mentioned, and is very seldom absent in all true cancers. The exceptions I refer to are mammary abscess dependent on lactation, and a deep-seated chronic mammary abscess the result of an injury.

It is not necessary for me here to describe the wellknown symptoms of acute inflammation of the mammary gland, resulting in abscess. Although the pain may be similar, the absence of extreme hardness of the tissues, and the disposition to form sinuses in the milder form of disease, will be ample guides in the differential diagnosis of these two maladies. Much difficulty may, however, be often felt in distinguishing chronic mammary abscess from a scirrhus. The pain is certainly, in the former, dull, heavy, constant, and wearying ; but it is not always free from the shoots, and darts which belong to the latter; and it is only by carefully sifting the evidence as to hereditary predisposition, injuries, age, &c., and taking into account also the somewhat less hard and less heavy tumour which forms the wall of an abscess, that we can approximate a diagnosis. The only positive method of distinguishing the two diseases is exploration by the grooved needle. This is neither a painful nor an injurious proceeding in either case, and is so decisive that it should never be omitted in any case admitting of doubt.

I will not say that adenoid, fatty, and fibrous tumours never give rise to the stabbing pain characteristic of cancer. But the pain I am speaking of is so rare a circumstance in these simple tumours, that its occasional presence by no means diminishes the important dia

gnostic value of this symptom. As in the diagnosis of any other disease, this symptom requires the support of its colleagues.

The only other very distinctive attribute of cancer is the disposition of the tumour to invade the neighbouring tissues; and substitute its own unhealthy material for the natural structures. This is observed in all the forms of cancer. The breast or the uterus will be converted into a scirrhous or encephaloid mass, leaving no trace of the original organ; and the tongue or lip may be entirely infiltrated with epithelioma, supplanting altogether the healthy muscular structure of these parts. This substitution of parts is not observed in other tumours, and the only approximation to it is to be found in tertiary syphilitic deposits in the muscles. The tongue occasionally becomes the seat of this kind of apparent substitution. It is wholly indurated, or there is a hard lump in some part of it, more generally the centre. The hardness, however, is not very intense, and very commonly there is a crack, or sinus, or several, which shall not have the hard everted edges of the sinuses observed in true cancer. The resemblance, however, of these two morbid states is sometimes so great, that we have to await the effect of treatment in resolving the doubt.

The various minuter points of distinction, by which we may know cancer from its allies and counterfeits, in the different organs and structures of the body, will be described when treating of the disease in its local manifestations. I have been content here to indicate the major signs, or symptoms, which of necessity accompany all cancers.