The importance of distinguishing one cancer from another, is of less practical value than the distinction of this from other diseases; inasmuch as the different forms of cancer are not infrequently found united in the same person, and occasionally exchange their peculiarities in the progress of the same tumour.

In times past we had a multiplicity of names, associated with the various growths which were supposed to be of a cancerous nature, and if I do not attempt an analysis of this nomenclature, and bring it into accord with the greater knowledge of the present day, I trust that I shall not be thought to slight the knowledge and abilities of the great surgeons who exhibited their skill in investigating and their ingenuity in giving names to these tumours. The microscope has so revolutionised pathology, that whereas formerly theories were founded on circumstantial evidences, we have now demonstrative facts to guide and govern them. Accepting, then, the nomenclature of the present day, as that which represents our knowledge upon this subject, we have to discuss the differences between scirrhus, epithelial, medullary, and colloid

cancers.

These may be fairly looked upon as representative forms of disease having sub-divisions which should be kept strictly in their subordinate position, in order that the student may not be confused by a multiplication of names which do not represent different things, but simply different stages of the same tumour.

Scirrhus is the form of cancer which prevails in three-fourths of the cases that present themselves at the Cancer Hospital; and I believe that about the

same relative proportion is observed at the Middlesex Hospital and at St. Bartholomew's. It should, therefore, take the lead in any description of cancer.

Scirrhus has its preference for the breast and the uterus, and these, as it happens, are the parts most prone to be selected as the seat of cancer. Of 4261 cases seen at the Cancer Hospital, 2745 were cancerous affections of the breast in man and woman. 712, the largest number next in succession, has reference to the uterus and vagina.

This, therefore, is the form of cancer which comes most frequently under the notice of the surgeon, and, from its resemblance to less formidable tumours, requires the utmost care and thought in arriving at a correct diagnosis.

A scirrhous tumour when first recognised is a very hard lump, the size of a walnut, attached to the neighbouring structures, and moving with them, not independently of them, as is the case in adenoid tumours. It is almost invariably a circumscribed tumour. You can handle it as you would a cricket-ball, and its weight is very considerable. You can press it between your fore-finger and thumb, and make no impression on it, and as a rule not give pain in so doing. At this stage we may or may not have the stabbing pain previously referred to; but if it be cancer, we shall almost certainly have a history of cancer or phthisis in some member of the family. Should there be authentic evidence of a blow, and no constitutional taint, there will be good reason to hope that no cancer is present. If the tumour slips glibly beneath the finger and thumb, has an almond shape, and is wanting in the extreme hardness I have

pointed to as characteristic of cancer, we may safely pronounce that the tumour is innocent.

This hard lump grows generally slowly, but sometimes rapidly. It attaches itself to the skin, or to the subjacent tissues; and gradually both these structures become involved in the disease. This is not the case in innocent tumours. Central disintegration is also going on, and the hard cricket-ball is giving way at its most exposed surface, so that the products of disintegration may have a method of escape. We have thus established an open cancer. Periodical sloughings very generally ensue as a sequence to this stage of the disease, and portions of the tumour are thrown off from time to time. In strong women I have seen the whole of the cancer thus eliminated, and a healthy cicatrix form over the seat of the disease. In the majority of cases, however, hæmorrhage which accompanies this process, reduces the powers of life too much to admit of this fortunate termination, and death ensues from exhaustion.

At an

There is happily another direction taken by a scirrhous tumour, in a very large number of cases. uncertain period, the unbroken scirrhus not infrequently ceases to increase. It then imperceptibly wastes, and the breast itself partakes of the atrophic action. The shrivelling of the tumour and of the gland go on simultaneously, and we have the satisfaction of seeing this formidable disease subside, with the loss only of the organ it had selected for attack. Examples of this atrophic cure are more numerous than is generally supposed: some instances will be found recorded in the course of this work. Scirrhus, as observed in the

uterus, and in the internal organs generally, has a more obscure history. It is not recognised until it is more fully developed, and when in the majority of cases it has proceeded to the ulcerative stage.

Scirrhus of the uterus is developed at an earlier age generally than scirrhus of the breast. The severe effects of parturition have an indisputable influence in lighting up the constitutional malady more quickly than it would otherwise show itself. The ulcerative stage succeeds very rapidly to the scirrhous condition, and from the position of the organ, as well as from the more obscure character of the earlier stage of the complaint, the application of remedies is more difficult and less beneficial than when the disease attacks the external organs. Great increase of temperature in the vagina is an invariable accompaniment of the scirrhous uterus, and few persons would fail to recognize the nature of such a tumour by digital examination only, from the sensation of cartilaginous hardness communicated to the finger. It is fortunate that such is the case, inasmuch as the use of the speculum is greatly to be deprecated, owing to the suffering induced and the frequent mischief done by its introduction. The sense of touch, in this instance, is certainly of far superior value to the sense of sight, in a diagnostic point of view.

It is said by Dr. Tanner that the medullary form of cancer is by far the more frequent in this organ, but I am not enabled to endorse this opinion. It is not at all unlikely that he has the opportunity of seeing this disease at an earlier stage than we generally see it at the Cancer Hospital, and when it may present itself in that nodular and vascular character which would obtain

the name of medullary. Coming as these patients do to the Cancer Hospital after an opinion as to the malignant nature of the disease has been given and consequently when it is in a somewhat advanced stage; we rarely find anything but a hard scirrhous ulcerating mass, by no means so vascular as is observed in the medullary cancer of other parts of the body, and not, as a rule, attended with such hæmorrhage as cannot be readily controlled by styptics. Epithelioma of the os uteri is not uncommon, and will be recognised by a tripe-like growth around the os, without an indurated base. It takes also the form of a spongy growth, of the denominated cauliflower excrescence,' and this also has no hard base, and may frequently be removed with favourable results.

Scirrhus of the stomach, and of the internal organs generally, are all sufficiently described in systematic works on medicine by eminent physicians, but I shall have a few remarks to make when considering the incidence of this disease in these various organs of the body.

The epithelial form of cancer comes next in frequency to scirrhus, and although it embraces very nearly all the cases of cancer in men, it still represents less than one-third of the cases of scirrhus. The numbers recorded at the Cancer Hospital are-Scirrhus, 3287; epithelial, 998.

The most frequent seat of epithelioma is the lower lip, then the tongue, then the penis, vagina, and rectum. The back of the hand is a curious, but not very uncommon point of attack, and when the fauces or œsophagus are unfortunately the subjects of this cancer, it is generally in the epithelial form.