malignant disease may, and does, in its later stages, spread by direct extension from the one organ to the other. But in the cases I am about to relate there was disease of both uterus and ovary, without obvious contact, so that it became a difficult thing to determine in which organ the disease was primary and in which secondary. Mr. Targett, who furnished the pathological report in both cases, was of opinion that in the first case the primary disease was in the ovary, and that in the second case it was in the uterus.

The first case was that of an unmarried lady, thirty-three years of age, who was sent to me on the 27th of June, 1901, with the history that, for about fourteen months, there had been a pink discharge in the inter-menstrual period with occasional menorrhagia. No examination had been made. The cervix uteri was found on examination per vaginam to be patulous and long. The finger passed easily into what appeared to be the uterine cavity, where there was a growth, easily made to bleed and easily detached. In Douglas's pouch, pushing the uterus to the front and to the left, was an irregular fixed swelling, equal in size to an ordinary orange. My diagnosis was that either both intra- and extra-uterine growths were malignant or tubercular, or they were nonmalignant and independent (ovarian dermoid or adenoma with adenoid vegetations of the endometrium). I recommended abdominal section, preceded by exploration and, if necessary, curetting of the uterine cavity.

On July 10, 1901, an examination per vaginam was made under anæsthesia. The cervical canal was found curiously and asymmetrically dilated. The os uteri internum was situated in the left upper corner of the expanded cervix, on the wall of the upper part of which the mucous membrane was covered with a soft growth. The os internum was sufficiently dilated to admit the finger. Some soft growth was felt on the lining membrane of the fundus similar to that found in the upper part of the cervix. This was removed with the curette and a portion sent for microscopical examination to the Clinical Research Association. On introducing the finger within the uterine cavity after the curetting, a hard,

smooth plaque was felt just beyond the os internum just like the half of an almond divided longitudinally. As the material removed by the curette had not, to the unassisted eye, a malignant appearance, it was decided to leave the uterus in situ until the microscopist's report had been received, and to proceed to abdominal section with the view of removing, if possible, the intra-pelvic swelling, which was now, under anæsthesia, felt to be equal in size to that of a fœtal head at term. The tumour proved to be a thin-walled multilocular cystic adenoma of the right ovary, one loculus of which was ruptured during removal. The tumour was adherent to the floor of the pelvis, to the lower part of the posterior aspect of the uterus, and to the back of the broad ligament. It measured about 5in. by 4in. At one spot there was a small projecting mass about the size of a small walnut, consisting of a compact mass of very small cysts, which gave it a solid appearance. There was some papilloma on the inner surface of the unruptured larger cyst. (Portions of both were sent for examination and report.) The tumour, having been separated and drawn out, presented a good pedicle of stretched out broad ligament. When it had been removed, the uterus was brought into view, and was found globular and bulky, like a two-months pregnant uterus, except that it was very firm. The left ovary was small, shrivelled, adherent, and calcareous. It was not removed. On the 20th of July, ten days after the operation, a report was received from the Clinical Research Association, signed by Mr. Targett, to the effect that the disease both in the ovary and in the uterus was carcinoma.

The following is a copy of Mr. Targett's report: --

Specimen 541.-This material from the uterus consists of a very soft columnar-celled carcinoma of the villous type. The tubular arrangement of the cells is well preserved, and the stroma is very scanty.

"Specimen 542.-The character of the carcinoma is best seen in this section from the right ovary. It shows a typical columnar-celled growth, and a marked tendency to the formation of small cysts which become secondarily filled with

intra-cystic papillary processes. There is abundant evidence of malignancy in the invasion of the surrounding stroma.

"Specimen 543.-This section at first sight seems to be a simple adenomatous intra-cystic growth, but on closer inspection it will be noted that there are many solid clumps of epithelium among the delicate papillomata. They are due to epithelial proliferation and indicate the tendency of the tumour, though here seen in its earliest stages.

"Apparently the disease is primary in the ovary and has extended to the uterus. J. H. TARGETT."

July, 19, 1901.

The patient was therefore advised to have the uterus extirpated per vaginam, and to this she consented.

Accordingly, on the 25th of July, vaginal hysterectomy was performed by my colleague, Dr. Walter Tate. The operation presented no special difficulty. There was a distinct hard lump, about the size of a Spanish nut and rough on its inner surface, situated in the anterior wall, towards the right side. There was no evidence of extension of the disease to the broad ligaments or to the left appendages. The latter were, however, removed as a matter of precaution. The parts were adherent in the neighbourhood of the stump on the right side, but the adhesions were easily separated. The patient recovered fairly well from the operation, but remained for some months pale, thin, and thoroughly unstrung. She spent the winter of 1902-3 on the Italian Riviera, and whilst there underwent the Weir-Mitchell treatment. The result was successful beyond anticipation, the patient gaining 22lbs. in weight during the six weeks. She returned to England looking bright and happy and the very picture of health. In the summer of 1903, about two years after her operations, she was married, her husband having been made fully aware of all the circumstances. Vaginal examinations had been made frequently ever since the last operation, but with entirely negative results until the 24th of November, 1903, when a little fleshy growth was detected at one angle of the scar in the vaginal roof. There had been a slight continuous blood-stained discharge for some time, and the little growth

bled easily on touch. I advised that this should be at once dealt with. I accordingly sent the patient to Dr. Tate, who regarded it as merely a little exuberant granulation-tissue, but quite agreed with me that it should be removed. This was done on the following day, and the specimen was sent to the Clinical Research Association for examination. The report was to the effect that the growth was distinctly carcinomatous. It has not, however, re-appeared. On the 17th of March of the present year, Dr. Tate and I found a soft swelling above the vaginal roof, equal in size to a pigeon's egg. Two days later Dr. Tate made an exploratory incision per vaginam, with the result of evacuating a smail collection of discoloured serum. The swelling thereupon disappeared. No evidence of new growth was detected.*

The second case was that of a maiden lady, aged fortynine, who had always enjoyed good health. I saw her for the first time on January 2, 1903, in consultation with my friend Dr. Horace Duncan. Since the beginning of October, 1902, she had suffered from a dull pain in the right iliac region, whilst for the last eight months the monthly periods had lasted longer than usual and had occurred at gradually shortening intervals. In December there had only been an interval of three days. The discharge had been dark, clotted, and occasionally offensive. I was unable to discover any evidence of swelling on even deep palpation of the abdomen. On vaginal examination the uterus was felt to be strongly anteflexed and anteverted, the body resting on the anterior vaginal wall and pressing it backwards. The os and cervix uteri were high up and difficult to reach; they appeared to be normal. There was an irregular, not very movable, illdefined swelling in the situation of the right uterine

* Whilst this Lecture was passing through the press, the patient was again discovered to have a swelling, this time equal in size to a closed fist, above the vaginal roof. Accordingly, on June 20th, 1904-it being now nearly three years since the first operation-it was de ided that the abdominal incision should be re-opened. The swelling proved to be a cyst connected with the remains of the right uterine appendages, roofed in by adherent viscera, and itself intimately adherent to the parts around. It contained reddish-brown serum without odour. Its wall, for the most part thin, smooth and friable, presented at one spot, a patch of soft, friable growth, equal in size to a hazel nut. The whole of the cyst, including the growth, was removed. No evidence of further extension or of glandular infection could be detected. The patient's general condition, in the meantime, is by no means unsatisfactory. Except that she had felt somewhat lacking in energy and had lost flesh slightly, she had had no symptoms. The swelling was discovered accidentally in the course of an ordinary periodical examination. It is now (June 30th) ten days since the operation, and she is making an excellent recovery. The growth from the cyst-wall has been examined microscopically and proves to be malignant.

appendages. It neither gave the impression of an out-lying fibroid nor of an incipient ovarian cyst. The note I made when I returned home was as follows:-" Considering the age of the patient, the pain and the anomalous nature of the swelling, there seems reason to fear it is a malignant growth, probably of the right Fallopian tube, but possibly of the ovary." Exploratory incision was advised with removal of the growth if it were found practicable, the operation to be preceded or supplemented by curetting of the uterus.

The patient's friends wished to have a further opinion upon the case, and accordingly a few days later she was seen by another obstetric physician, who was inclined to regard the tumour as a fibroid; at any rate, he did not think it was malignant. With reference to operation, his advice to the patient was to wait for the present. "It could not possibly do any harm," he said, " to wait a few weeks.”

Dr. Duncan watched the case, and as he considered the development of the growth was too rapid to be consistent with the diagnosis of fibroid, he asked me to see the patient again with him on the 20th of February. The swelling was now easily apparent on abdominal palpation, as a rounded, hard, well-defined, slightly movable tumour, situated in the right iliac region. Bimanually, it was still obvious through the vaginal roof, the abdominal development being evidently due, not to alteration in the position of the tumour, but to increase in its size. There was also now perceptible a smaller but equally hard swelling in the left iliac region. The uterus was anteflexed, and appeared to me to be of normal size.

My opinion as to the malignancy of the growth and also as to the desirability of an exploratory operation was confirmed. On this occasion my suggestion was adopted. Accordingly, on the 25th of February, 1903, I opened the abdomen. The mass on the right side was found to be a soft growth, evidently malignant, of the right ovary, partly cystic and containing in its centre thick, yellow, turbid fluid, apparently pus. It measured 5in. by 4in. by 22in., and was adherent to the walls and floor of the pelvis. The mass on the left side was of the same character, but smaller, measuring 3in. by 2in. by 2in. It also was breaking down in the