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had good health for four and a quarter years or more.

If a growth which was fixed and inoperable beforeoophorectomy became smaller and moveable after the opera-tion it was advisable to excise it as soon as the resultingimprovement ceased to be definite. The removal should bevery freely carried out, as it was probable that a certainnumber of cancer cells still remained in the immediateneighbourhood of the obvious growth, in the tissues which,though now apparently free, were at one time definitelyinvolved; for in many of the cases in which the disease hadcompletely disappeared after oophorectomy it had subse- Iquently reappeared in the same situation. The most favour-able age of operation was from 45 to 50 years ; in relativelyyoung patients it should be given a further trial, but after50 it was rarely worth doing. The fact that the patienthad passed the menopause did not contra-indicate the opera-tion. Secondary growths in the viscera contra-indicated theoperation ; rapidity of growth or an early recurrence afterthe primarv operation made the prognosis unfavourable.The mortality in this series of cases was high, a littleover 6 per cent. It should be noted, however, that theactual cause of death in several of these cases might beregarded as accidental ; in two the fatal issue was due topulmonary embolism and in one to acute mania. The

changes which had followed oophorectomy in the successfulcases were still unexplained but it was possible that a morbidvariation of the ovarian secretion might be one of the pre-disposing causes of cancer of the breast and that when themalignant changes had once begun their further develop-ment might be favoured by this secretion, and in these casesremoval of the ovaries might meet with success if the diseasehad not already advanced too far. Carcinoma not in-

frequently developed in a breast which was already the siteof chronic mastitis and it might be that there was a con-nexion between the secretion of the ovary, one or more ofthe varieties of chronic mastitis, and mammary carcinoma.

Mr. W. BRUCE CLARKE showed a case of a woman fiveyears after oophorectomy for inoperable cancer. In 1895the patient had some bloody discharge from the nipple butno evidence of growth. In 1897 a small nodule was detectedand removed and three months later the whole breast wasremoved and the axilla was cleared out. The growth on sectionproved to be a duct cancer. In 1898 the posterior trianglebecame involved and the growth was removed from thissituation. In 1899 a further recurrence took place in thissituation and the growth was again removed. In November,1899, the growth had again recurred and involved the right

.side of the chest. Oöphorectomy was now performed. Thepain, which had been a marked feature, rapidly diminished ;the growth shrivelled in six weeks and had remainedin about the same condition till the present time, somefive years after the operation. This was the most successfulcase that had come under his own observation but in all thecases upon which he had operated some improvement hadfollowed the operation. He never used this method exceptin inoperable cases.

Mr. J. STANLEY BOYD said that the conclusions whichhe had drawn from a smaller number of cases coincidedwith those of Mr. Lett. He was of opinion that thechronic cases were those which gave the best results. Inone of his own cases the cancer of the breast had existedfour and a half years before the oophorectomy wasperformed and the patient had now lived 12 years since theoperation. In Dr. Herman’s case the cancer had existed forsix and a half years before the operation of oophorectomyand the patient lived 12 years. The cases reported byWatson Cheyne, Beatson, and Edmunds all showed the samechronicity in the primary growth or the greater resistance ofthe patient to the growth. He did not think oöphorectomyas a primary operation was advisable but he had in two orthree instances used the combination of methods-viz.,removing the breast and the ovaries-with results which hedid not think could have been obtained by the removal of thebreast alone.

Mr. JONATHAN HUTCHINSON pointed out how difficult itwas to obtain evidence with regard to the duration of car-cinoma of the breast. He referred to the case of a mostintelligent woman who had a large cancer of the breast inwhich the growth was stated only to have been present for aweek. He then referred to cases in which carcinomatousgrowths had spontaneously disappeared. He thought that notime-limit could be fixed with regard to the recurrence ofcarcinoma of the breast and mentioned the case of a womanfrom whom he had removed the breast and the growth only,

returned ten years after the removal. The patient died: 11 years after the operation.. Dr. G. E. HERMAN said that the paper showed two veryimportant points-viz., that those cases did best when: operation was performed about the menopause and that the. treatment with thyroid gave beneficial results.! Mr. W. McADAM EccLES said that there were three points

to which he would allude. First, he attached considerableimportance to the nature of the carcinoma, for the variation

. in the rapidity of growth was considerable; secondly, hethought that much might be learned from the microscopicalexamination of the ovaries removed; and, thirdly, theexamination of the shrunken growth was important and sofar as he knew only one such case had been examined. Hementioned a case in which oophorectomy had been performedfor extensive cancer in which all the nodules atrophiedexcept for one or two small points. The patient lived for26 months after the oophorectomy and 35 months after theprimary growth had been removed. This patient had beenthe subject of a most violent "nerve storm" after theoöphorectomy but recovered completely in about ten days.Mr. PEARCE GOULD pointed out the fallacy of the statis-

tical method of collected cases for only the more successfulones were published. His experience of the results of thisoperation had not been so favourable as that of Mr. BruceClarke and he had seen but one case with a strikingresult. In this instance rapid diminution of the growthtook place but the patient unfortunately died from intes-tinal obstruction. Sections of the atrophied growth showedconsiderable fibrosis and atrophy of the cell elements.He never felt able to press the operation on a patientwhilst the knowledge of the nature of cancer was so un-certain. He had not infrequently seen arrest of the diseasewithout any operation. It was clear that there were physio-logical means by which the disease could be arrested and helooked forward to the time when these physiological meanswould be known and rightly applied.Mr. LETT replied.

MEDICAL SOCIETY OF LONDON.

Disoussion on Hæmaturia.

A MEETING of this society was held on Jan. 23rd, Mr.JOHN LANGTON, the President, being in the chair.

Dr. A. E. GARROD, in opening the discussion, said thatalthough the presence of blood in the urine was often a sym-ptom of great diagnostic value the interest and importancewhich attached to it were almost entirely clinical. It raisedno abstruse pathological problems as did the presence in theurine of products of deranged metabolism, with regard towhich the kidneys merely played the part of excretory organs,whereas they had their origin in morbid processes behind therenal barrier. In this respect the two very similar conditionshasmaturia and hæmoglobinuria stood in conspicuous contrastto each other. He next dealt with the diagnosis of haemat-uria and said that, as a rule, this gave rise to but little

difficulty ; occasionally the differentiation of haematuriafrom haematoporphyrinuria presented some difficulty if theurine rich in hasmatoporphyrin happened to contain albumin.The microscope would usually serve to remove any doubt.Spectroscopic examination did not supply so delicate a testas was sometimes supposed. If the blood pigment in theurine were always present in the form of oxyhasmoglobin itwould be a different matter, but the band in red of methasmo-globin was not nearly so distinct as that of the latter pigmentwhen dilute solutions were examined. The port-wine colouredurine rich in hæmatoporphyrin often showed a pair of absorp-tion bands which closely resembled those of oxyhæmoglobin.Dr. Garrod then dealt with the chemical tests for bloodpigment and stated that with the exception of Teichmann’shæmin-crystal test the tests were not so satisfactory as

might be wished but they served very well in practice. Theozonic ether and guaiacum test was one of extreme delicacyand the failure to obtain the blue rings, at any rate, affordedmost satisfactory evidence of the absence of blood. The

microscopical -characters of the urine from cases of hæmat-uria were then considered and perhaps one of the mostdefinitely diagnostic objects which could be found wasthe ovum of bilharzia hagmatobia. The presence oftube casts, of renal epithelium, or of fragments of tumourswas of the greatest diagnostic importance. He then

alluded to a definite group of cases of hæmaturia occurring

229

as an isolated symptom in infants in which the cause

was the presence in the urinary passages of crystals ofuric acid. A still more important cause of hasmaturia in theearly months of life was infantile scurvy and he stated thatblood was present in the urine at some period of the diseasein the majority of -such cases. The hasmaturia in these caseswas in no way proportionate to the severity of the disease.In some cases it was an isolated symptom. Passingover such causes as nephritis and renal and vesical calculusDr. Garrod next dealt with cases of hasmophilia in which6xmaturia had occurred. In other cases hasmaturia wascaused by eating rhubarb and this occurred in some cases aftera large amount had been consumed, in others when only asmall quantity had been taken. He quoted several instancesof this form of hasmaturia. Among the rarer forms ofhsematuria, the origin of which was quite obscure mightbe mentioned the cases of idiopathic or congenital hereditaryand family hasmaturia, no less than 12 members ofone family being affected. The hsematuria persistedfor many years but in some cases it would cease

but would recur or increase in a paroxysmal manner.Some obscure cases of haematuria had been described inwhich when an operation was performed no conspicuouslesion was found. In one case reported by Mr. HurryFenwick a localised interstitial change was present. Amongconditions in which hagmaturia was the sole symptomreference was made to that due to bilharzia hasmatobiawhich wns not very rarely met with in the young men whohad returned from South Africa. He then referred to thehæmaturia in cases of parenchymal nephritis and that whichoccurred in granular kidney, moveable kidney, and lastly tothat which occurred in association with prostatic diseases.In conclusion, he referred to the term "renal epistaxis" which suggested that the bleeding might occur from thekidney, as it did from the nasal mucous membrane, withoutany gross lesion.

Dr. H. E. BRUCE PORTER mentioned the case of a man,aged 50 years, who had two attacks of hasmaturia which weredefinitely connected with the taking of a large quantity ofasparagus. In this case no oxalates were present.

Mr. T. H. KELLOCK said that he had seen hasmaturiafollow a papillomatous growth in the kidney. He mentionedthe case of a young man with a tumour in the left kidney.This was removed and if. was found that the whole pelvis was filled with a papillomatous growth. Papilloma of the bladder gave rise to more severe hasmaturia than almost any other condition. He did not believe that hæmaturia was a commonsymptom of renal sarcoma. He was of opinion that a (

calculus in the cortex of the kidney more often gave rise to !’

hsematuria than a large calculus situated in the pelvis. ^

r

Dr. J. H. BRYANT referred to the great diagnostic value ofthe cystoscope. In one case of a man, aged 40 years, withprofut’e hsematuria and enlargement of the right kidney, itwas found on examination that a large villous growth sur-rounded the orifice of the right ureter and so far gave riseto obstruction and hydronephrosis. The patient made acomplete recovery after the removal of the growth from thebladder. In a second case blood could be seen oozing fromthe left ureter. Bacteriological examination was also ofvalue in such cases.Mr. R. H. J. SWAN referred to the value of the cysto-

scope and the separator. Even in cases of profuse hasmat-uria it was often possible to make a diagnosis in a fluidmedium in the bladder which was not quite clear. A rapidexamination often sufficed to make the diagnosis obvious.He said that in tuberculous cystitis hæmaturia might be theonly symptom. He related the case of a small boy whosebladder had been opened under the supposition that a

papilloma was present. Nothing was found but by subse-quent examination with the cystoscope a tuberculous con-dition was seen. He thought that hæmaturia as the onlysymptom in cases of enlarged prostate was very rare.

Dr. F. J. POYNTON referred to hasmaturia occurring ininfants suffering from scurvy without any other symptomsHaemorrhage from the kidney occurred in cases of malignantendocarditis, partly due to infarcts but also due to a toxicnephritis. In one instance in which he had injected a catwith a virulent growth of streptococci the animal haddeveloped a nephritis from which it completely recoveredand when killed subsequently the kidneys were found to be J

perfectly normal. (The PRESIDENT referred to the rough clinical tests for the (

diagnosis of the source of hæmorrhage-viz., that when 1intimately mixed with the urine the blood probably came ifrom the kidney or ureter when following the passage of clear i

urine from the bladder, and when at the commencement of, micturition as coming from the urethra. He referred to the: ca-e of a man with all the symptoms of stone in the kidney.He explored the kidney but was unable to find any calculus.

! The man made a complete recovery and was perfectly well18 years later. He thought that hasmaturia was more com-monly the result of small calculi than of large ones.

Dr. GARROD replied.

LIVERPOOL MEDICAL INSTITUTION.

; Exhibition nf Instrzcnaents.-Bon,y Deposits following Injury.-Cerebellar Abscess. -Acute Labyrinthitis. - TyphoidFever.A MEETING of this society was held on Jan. 19th, Dr.

JAMES BARR, the President, being in the chair.Dr. W. BLAIR BELL exhibited and demonstrated the use

of the following instruments: (1) Combined PeritoneumForceps and Wound Retractor; and (2) Complete InfusionApparatus, with improved Venous Cannula.Mr. ROBERT JONES and Dr. DAVID MORGAN presented an

Analysis and Radiographic Illustrations of 16 cases of BonyDeposits following Dislocation of the Elbow-joint under theirobservation. The=e deposits had followed simple disloca-tion, unaccompanied by fracture, and were not associatedwith myositis ossificans progressiva. They differed frommyositis ossificans due to local irritation and their occurrencein presence of a fracture was not associated with callus.The periosteum was believed to be the origin of these

bony deposits. A series of radiographic lantern slides

depicted their growth, from slight shadows to dense bonyformation. The diagnosis and the prognosis were discussedand microscopic slides were shown to demonstjate theirtrue bony nature as distinct from calcareous changes.Mr. W. T. CLEGG read notes of a case of Cerebellar

Abscess which occurred as the result of acute ear trouble.The clinical history of the case was given and thedifferential diagnosis between temporo-sphenoidal and cere-bellar abscess was discussed. An operation had been per-formed but without relief to the patient. At the necropsya large abscess was found in the right lateral lobe of thecerebellum, the infection having travelled from the earalong the sheath of the auditory nprve. There was nomeningitis.

Mr. CLEGG also related a case of Acute Labyrinthitis in achild, two years and eight months of age, in which the

symptoms closely resembled tho-4e of meningitis. Afterrecovery deafnes persisted. There had been no dischargefrom the ear.

Dr. NATHAN RAW read a paper on Some Points in the

Diagnosis and Treatment of Typhoid Fever based on anobservation of 362 cases treated in hospital during the last16 years. He referred in detail to the great difficulties indiagnosis which many cases presented in the early stages ofthe disease and discussed the value of Widal’s re action as anaid to the practitioner. Hæmorrhage and perforation werethe two most formidable complications and a careful résuméof the symptoms of perforation of the intestine was given asit was highly important to be able to diagnose its immediatemset so that prompt operative measures might Le adopted.In his opinion the treatment of the future would be directedawards reducing the virulence of the bacilli and the onset)f toxasmia on the lines suggested by Dr. A. E. Wright or)y the introduction of a serum. The cold or continuous)ath treatment undoubtedly in other countries gave betteresults than any other, but he believed it would be some con-iderable time before it was generally adopted in this countryr. the treatment of typhoid fever.-Dr. W. CARTER consideredlrieger’s suggestion of feeding patients suffering from

yphoid fever with pure peptones good and he htd carried into practice for many years. Commenting upon Widal’s re-ction. he mentioned two cases in which it proved misleading.- Dr. W. B. WARRINGTON considered that even when much,are was taken the serum reaction was not devoid of am-

iguity and the observer was from time to time left in doubt.4 to the positive or negative nature of the reaction.-Dr.. E. ROBERTS was of opinion that the mortality of entericiver in Liverpool, when treated in hospit’d under modernconditions, would average about 12 per cent. He based thishis experience of close upon 2500 ca-es treated at the city

hospitals since 1892. The mortality of this disease w as greatlyfluenced by the cla"s of patient under treatment, and asustrating this point Dr. Roberts said that he had never lost