centre and was adherent in the pelvis. Both growths were removed with difficulty, leaving behind thick tags of adhesion. Before the abdomen was opened, the uterine canal had been dilated and curetted. A large quantity of soft growth had been removed, and the instrument had revealed a ragged deep excavation in the posterior wall of the corpus uteri. It was evident that there was carcinoma of the body of the uterus. Now that the uterus could be examined from above, there was seen to be a small, rounded, hard projection from the middle of its posterior aspect. (This afterwards proved to be a fibroid.) The peritoneum covering the uterus was unaffected. The propriety of supplementing the removal of the ovaries by the removal of the uterus was discussed, but, as the prognosis seemed hopeless, as the operation had already been long and severe, and as the anesthetist had already had difficulties in regard to respiration, it was decided not to attempt it.

The patient made an unexpectedly satisfactory recovery, and on the third day I began to be exceedingly unhappy at the thought of having left the uterus unremoved. I therefore proposed that at the end of a week from the day of operation, if things should continue to go well, I should be permitted to re-open the abdomen and extirpate the uterus. This having been agreed to, I proceeded on the 4th of March to perform the operation, the vaginal attachments of the uterus having previously been separated by Dr. Tate, and the cervical canal closed by means of a suture. The adhesions about the stumps left at the operation of the previous week were numerous, and the mass formed by them on the left side was so considerable in size and so hard that on bimanual examination before operating it had been feared that the disease had already spread. On laying open the uterus after its removal, it was seen that the malignant growth, which involved the whole mucous membrane with the exception of an islet here and there, had penetrated into the muscular coat, but had not extended beyond the tissues of the uterus itself. There were several small fibroids; one of these was equal in size to a cherry, half being imbedded in the posterior uterine wall and half projecting from it.

The report from Mr. Targett was as follows:

“March 5, 1903. The growth removed from the uterine cavity is a very soft carcinoma of the columnar-celled type. Owing to rapid proliferation the cells do not form tubules, but are arranged in large alveoli with very little intervening stroma. The growth in the ovary is also a soft carcinoma like that of the uterus, and its columnar-celled character is more distinct. In many of the alveoli there are small cystic spaces due to mucoid degeneration. I think this growth is secondary to [that in] the uterus. It is unlike a primary carcinoma of the ovary."

The uterus having been forwarded after its removal, Mr. Targett sent in a further report, dated May 7, 1903 :

"The sections prepared from the edge of the growth show the structure very well, viz., a columnar-celled carcinoma of the type that would originate in the endometrium of the body of the uterus. The cells form imperfect tubules and irregular masses which have already penetrated the muscular substance of the uterus to a considerable depth. There is nothing in the character of the cells or their arrangement which would suggest that this was a secondary growth. . . ."

I had an opportunity of seeing and examining the patient on the 27th of last month (April, 1904). She had been remarkably well since the operation, now fourteen months ago, and had been able to pay a number of visits in various parts of Scotland and elsewhere. There had been no unpleasant symptoms beyond some hæmorrhage from the bowel during, and immediately after, defæcation (which manifestly had its source in some internal hæmorrhoids), and, during the last few days, some indefinite discomfort in the pelvis which interfered with walking. I could find, on examination, no definite evidence of recurrence. There was certainly some irregular thickening to be felt between the bladder and the upper part of the rectum, but only such as might be accounted for by matted adhesions following operation. It is, of course, too early to say what the ultimate result will be. But even as matters stand, I cannot regret having performed the

operations. Indeed, my only regret is that I was not permitted to operate when I first proposed operation, and that several weeks of very valuable time were lost.

My object in these lectures has been to encourage a spirit of hopefulness in dealing with apparently malignant cases, and to furnish a few examples of what may be gained by active surgical interference even when the probabilities have seemed to be overwhelmingly against success. I know from experience, as, indeed, every one of us knows, how helpful i is when one has to decide what course to advise in difficult and unpromising circumstances to be able to cast one's mind back upon some similar case either in one's own experience or in that of another. And it is because I have felt the enormous value of a concrete example of pluck rewarded, that I am going to conclude with a story which it was my privilege to communicate to the Medical Times and Gazette a good many years ago, viz., in 1881, and which, though it does not come strictly within the special subject of these lectures, exhibits such a triumph of perseverance, and has so often proved a source of encouragement to myself, that I make no apology for re-telling it. The story was committed to writing by the patient herself, the wife of a country clergyman, and was recorded in the Medical Times in her own words.

I will epitomise it as briefly as I can. It was in February, 1837, when this lady, a healthy young married woman expecting her confinement in about three months' time, first perceived a small lump in the right breast. This lump remained much about the same size during the next few months, but, on her again becoming pregnant, it grew considerably, and three months after her second baby was born the whole of the right breast was removed by a well-known Manchester surgeon, Mr. Thomas Turner. The cicatrix never seemed quite healthy. There was always a small lump, which about seven months later burst and discharged a small quantity of water. Another operation was now deemed necessary, and, though only two months were to elapse before she was again to be confined, it was performed by Mr. Thomas Turner on October 26, 1839. The wound was this time left open, and

took two months to heal. Her child was born on the 28th December, and soon afterwards there were noticed some unhealthy appearances in and above the cicatrix. She nursed her baby for four months, and then, by the advice of Mr. Bickersteth, of Liverpool, consulted Sir Benjamin Brodie. He and Mr. Travers held a consultation, with the result that she remained in London seven weeks under the care of Sir Benjamin Brodie, who, on three occasions, applied caustic potash and, on one occasion, chloride of zinc. The latter application was attended with extremely severe pain which lasted for forty-eight hours. It was hoped these applications had been effectual. The patient returned home, supposed to be cured, though there was a small wound yet unhealed. This, instead of healing, assumed a hard, raw aspect, and became a large nodule which grew rapidly. The local practitioner now took charge of the case, and from August 1, 1840, until October, applied various caustics to check the progress of the disease. In October, the patient was prevailed upon to try the then popular remedy of brandy and salt, but under this treatment the disease rapidly gained ground. It was then proposed to strangulate the now enormous growth by means of silk ligatures tied firmly around its neck and tightened every two days. This treatment, which was horribly painful, lasted for two months, at the end of which time the greater part of the mass had sloughed off and the rest was divided with scissors. As there still remained much to be destroyed, the caustics were now resumed. They were applied once, twice, or thrice a week or every ten days, as the growth seemed to require. Occasionally the growth was very rapid; at other times considerable portions sloughed off. Before the patient's fourth confinement on October 11, 1841, the size had been much reduced and the growth remained very small until some weeks after delivery, when it again commenced growing and the patient became very weak and ill. About the middle of December she was induced to try another remedy, viz., plasters of cobblers' wax covered with saltpetre. These caused excruciating pain and much sloughing, but the disease gained in spite of them and the old

treatment by caustics was resumed. The caustics used were of various kinds-potash, arsenic, and nitric acid. The application of the last-named always made the patient exceedingly ill for several days. The general health had now become much worse, and the patient's sufferings were augmented by the occasional formation of small abscesses near the inner border of the growth.

In September, 1842, the patient went to Paris to consult M. Canquoin. The excrescence then measured about 6in. in length by 7in. in breadth, and was a full inch in thickness above the surface of the body. The surface of this growth was raw. On the 8th of the month, Canquoin, with the assistance of two other doctors, was engaged for an hour and a quarter in removing the whole of this mass by means of caustics. Further severe applications of caustics were made on the 10th of September, and on two subsequent occasions (September 28 and October 5). Milder applications were made on October 13, 14, and 15, but on the 22nd and 25th it was again necessary to apply severe measures. The greater part of the ulcerated surface had by this time become much more healthy, but one small portion near the sternum still remained refractory. It was to this portion that the caustics had been applied on the last six occasions. There still, however, remained something that needed to be destroyed. Accordingly, on the 2nd of November, Dr. Canquoin, in the presence of the two other doctors, again applied the crayon caustics for nearly three-quarters of an hour. The suffering was intense, but this was the last application that was required. For, on the 15th of November, to the patient's "unspeakable joy," Canquoin assured her that the disease was completely destroyed and that no more caustics would be necessary. The wound now diminished daily, and healing took place healthily and evenly. The whole wound had become closed over on January 31, 1843, six years from the first appearance of the disease. A scab subsequently fell off, leaving a superficial raw surface, but this only remained open for about three weeks, and was entirely and finally healed on the 3rd of March, 1843.