scarcely any impression is made on the cancerous growth, inasmuch as it reappears almost as soon as the slough has been thrown off. This warty epithelioma invades the whole pudendum, extends to the groin and to the nates, and is kept in check only by generous diet, rest, and cold water-even iced-to the part. It is possible that, if it were recognized when the whole of the disease could be cut away, we might by so doing obtain that amount of immunity which attends operations for epithelial cancer in other parts of the body.

Cases of cancer of the vulva are generally so far advanced when seen by the surgeon, that he has rarely an opportunity of excising the diseased part, with much hope of benefit. Mr. Hutchinson has collected thirteen cases of cancer affecting these parts which have been treated by operation, and by some lucky chance three of these have a history subsequent to the operation. Mr. Smith of Leeds excised the clitoris and nympha of a woman aged forty-six, from which she recovered. The disease returned quickly (a few months) and was again excised, but recurred a third time before the wound healed. A woman aged seventy-one was operated on at Bradford for cancer in the right labium, existing six months. It returned in three months in the opposite labium, and the glands becoming enlarged, and her health failing, no further operation was proposed. A woman aged fifty was operated on by Mr. Hutchinson himself. Both labia and clitoris were affected, and there was a large mass in the left groin. It had existed one year. The whole of the disease, including the mass in the groin, was dissected away. She recovered well, but the disease returned in the cicatrix

within two months of the operation; of this she died about six months later. There is also a case, reported in the same number of the Medical Times' from which I have taken the above, operated on by Mr. Ward at the London Hospital.

Mrs. P., a very stout, florid, and healthy-looking woman, aged forty-two, was under Mr. Ward's care in July last on account of a small ulcerated epithelial cancer of the left labium. The sore was situated near the junction of the greater with the lesser labium, and was surrounded by a warty induration presenting a very characteristic appearance. The woman stated that it had existed about six months, and had caused a good deal of shooting pain. She knew of no history of cancer having ever occurred among her relatives. She did not consider that she had lost her health since the appearance of the sore. She was married, had borne two children, and her menstruation still continued quite regular. On July 11, Mr. Ward excised the diseased part. There were at the time no glands noticeably enlarged in either groin. The wound healed well, and she left the hospital in about a month. She was readmitted on September 11, on account of enlarged glands in both groins. In the left groin there was a good deal of inflammation and swelling, threatening abscess, and the exact state of the glands could not be ascertained, but in the right there were several isolated and hardened glands of considerable size. The scar in the vulva was perfectly sound. On being questioned, the woman said she thought she had felt a pricking pain in the groin within a fortnight of the operation. She had not thought it worth mentioning. She has still the appear

ance of good health, but has slightly lost flesh during the last month.

This case is of much practical importance as illustrating the rapidity with which the glands sometimes become involved in cases of epithelial cancer. As we have seen, the primary disease was excised within six months of its first appearance, and yet within three months after the operation, we have the lymphatic glands in both groins so extensively implicated as to put the case beyond the hope of further interference. It must be remembered that the patient is very fat, and that it is consequently possible that glands in a slight state of enlargement may have existed at the time of operation, which could not have escaped observation had the patient been thinner.

An equally instructive case is given in the Medical Times' of November 3, 1860:

E. H., aged fifty, a tall, stout woman, of lymphatic temperament, was admitted into the York County Hospital in May 1849, under the care of the late Mr. H. Russell. The clitoris and commissure of the labia minora were involved in a warty and florid growth of ephithelial cancer, about the size of a crown-piece. The disease had commenced about four months before her admission, and had latterly been attended by severe pricking pain. The urethra was not involved, and the inguinal glands were not enlarged. The hymen was perfect, and extended so far forwards that the opening into the vagina only admitted a full-sized catheter. The woman had been a housekeeper in a nobleman's family, and had lived comfortably.

After a week or two spent in preliminary treatment, in the hope of improving her general health, Mr. Russell

excised the diseased part, leaving the wound to heal by granulation. She left the hospital with a sound cicatrix on July 28, six weeks after the operation.

On November 23, information was received that she was suffering from shooting pain in the cicatrix. She was readmitted a month later, when a large cancerous ulcer was found to exist. She was much out of health, and the glands in the groin were swollen. The disease now rapidly advanced, and she died a few months later -about fifteen or sixteen months from the commencement of the disease, and ten from the date of operation.

Although the reappearance of the disease in these cases was so rapid, it does not follow that such is the invariable result, for we find in Dr. Tanner's useful collection of cases of cancer of the female sexual organs that in one case at least, in which he operated, the patient was freed from the disease for three years. Elizabeth D., aged 25; married; had one child five years ago, born dead after a bad labour. Admitted February 15, 1850. Had epithelial cancer of the labia minora or nymphæ. The labia majora are healthy ; but the lesser labia are enlarged into three warty-looking masses, each rather larger than a hen's egg. Two of these masses are on the left side of the vulva and one on the right. She states that the disease began soon after the birth of the child. On the 25th February he removed the growths, excising every trace of the disease. The copious hæmorrhage which followed the use of the knife was checked by the application of seven or eight ligatures and pressure. By the 9th March she had recovered, without a single unfavourable symptom. On the 24th March, 1853, this woman again came

under Dr. Tanner's care, the disease having returned in the labia majora. These parts then formed two large oedematous warty-looking masses, each labium being about the size of the open hand, but much thicker. In consequence of her aversion to any operation, trial was made of the effects of intense cold, by the systematic use of a mixture of ice and salt in a bladder. As no benefit was derived from this treatment, she left the hospital, and was not seen again after the 30th May.

It may seem a curious circumstance, but it is nevertheless true, according to my experience, that the young and the old offer better examples of the arrest of epithelial cancer generally by operation, than do those who have only just passed the climax of life; and I believe it was because of the youth of the last-mentioned patient that the disease was slower in its development, and the operation gave a much longer immunity from the disease, than in the other cases.

The palliative treatment of this affection should consist of the same supporting tonic medicines and food, previously advised, whilst the local applications should be of a sedative shielding character, taking care, if possible, by the use of the catheter, to avoid the irritation set up by micturition. The preparations of zinc and lead, and perhaps occasionally a weak solution of corrosive sublimate of mercury, or, if necessary for deodorizing purposes, a solution of permanganate of potash, are the applications most generally useful. Any caustic gives intense suffering when applied to this part, and does not afford results which justify the surgeon in putting his patient to so much torture. In fact, I doubt whether the disease is not in most cases accelerated, when so treated.