The lantern pictures which follow will help to fix in mind pictures of the scenery, the people, and the work in our three principal stations. During the last year we have established three new stations to be manned or strengthened by those recently finishing their second year of language. study on the field. The first two years are spent almost entirely in hard study of the difficult language of Arabic with its fifteen conjugations, complicated grammar constructions, rules and innumerable exceptions.

With the doctors that went out last year and the one sent out by the University this year to strengthen our force we hope very soon to have at least two doctors at each station so that one may take medical tours into the interior while the other stays by the work in the hospital, as it is desirable to always have a doctor at each station while others are on furloughs or vacations. In case of sickness of one physician more physicians will enable us to have assistants in large operations and in the overwhelming work to be done at each station. Last but not least increase in our force will enable us to go into puzzling cases with more detail of analytic and microscopic research which has been impossible in the past on account of stress of work. Then too there are many tropical diseases peculiar to our fields that should be investigated and worked out not only for better immediate results in our work locally but to the advantage of medical science in general, to which medical missionary work has already added no small part, which has often been unacknowledged by authorities. This has in some cases I think been due to a tendency to belittle this work by scientific writers but more especially due perhaps to the small amount of work reported in proportion to the amount done by such workers.

In the name of the five medical missionaries from the various corners of the earth that are with us tonight, I desire to say that we appreciate the cordial welcome this society has given us.

TRANSACTIONS.

CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.
STATED MEETING MARCH 8, 1911.

THE PRESIDENT, REUBEN PETERSON, M. D., IN THE CHAIR.
REPORTED BY JOHN WILLIAM KEATING, M. D., SECRETARY.

READING OF PAPERS.

MEDICINE IN CHINA.

DOCTOR CHARLES THOMPKINS, of Suifu, West China, read a paper bearing this title. (See page 113.)

MEDICINE IN INDIA.

DOCTOR LESTER N. BEALS, of Wai, India, read a paper on this subject. (See page 115.)

MEDICINE IN ARABIA.

DOCTOR SHARON THOMS, of Muscat, Arabia, read a paper which treated this question. (See page 117.)

REPORTS OF CASES.

A CASE OF ABSCESS OF THE BRAIN IN A CHILD OF FOUR.

THIS patient was

OPERATION. RECOVERY.

R. BISHOP CANFIELD, M. D.
Department of Otolaryngology.

referred to this clinic from the Neural clinic with the following history: Child is four years old and well developed. Last March she fell on a toy boat, the mast of which was represented by a knitting needle. The needle entered the orbit just below the eye. A piece of the needle two inches long was removed immediately, and the wound healed. It did not affect the eye-ball or vision apparently. The wound healed within a few days. After that she complained of headache, vomiting, more or less constant sleeplessness and about four weeks after an incision was made at the inner side of the eye-ball from which pus escaped. Six weeks later Doctor Slack, of Saginaw, operated on the orbit and removed another piece of steel about two inches long, which showed blunt and broken ends. The parents believe that the needle was broken off before the accident happened and that this part is the end of the needle, but this is not absolutely certain. The child remained well after this part was removed until about seventeen days ago when she began to complain of headache, sharp and piercing in character, vomiting and sleeplessness, but no dizziness, nor staggering. When the trouble began seventeen days ago, she complained of pain only in the left frontal region, but now the pain is on both sides. She has not been vomiting as much new as at the beginning and has only a slight fever. The temperature has been moderate, from 99° to 101° or more in the evenings. She has not had any cross eyes in the last seventeen days. The parents say that there is no rigidity in the back of the neck. She is irritable to noises and light, but apparently not excessively so.

On December 10, 1910, the patient was transferred to this clinic for operation. Examination at this time was negative. Under this date the following operation was performed. The usual frontal sinus incision through the left eyebrow to median line, vertical incision upward two inches in median line, periosteum retracted, cortex negative. Frontal sinus opened and found negative. Entire antral wall removed. Area of dura uncovered one inch in diameter corresponding to upper half of the posterior wall of frental sinus and extending upward. Dura bulged strongly forward, pulsation marked. U-shaped flap, base upwards onehalf inch in diameter, followed promptly by small brain hernia. Brain incised in all directions, negative. Dural flap sutured with catgut, skin incision sutured for primary union.

The following day the patient was in good condition, temperature 100', pulse slightly irregular, pain in the head slightly greater than before the operation. For the following week the temperature was normal, the patient had no pain, and there was marked improvement in the subjective condition. On December 23, and for two or three days previous, it was noticed that the patient was becoming somewhat more restless, took

less interest in surroundings and complained of headache. On the 22d her general condition seemed decidedly worse. On the 23d she relapsed into semiconsciousness from which she was aroused with difficulty. There was a slight swelling of both optic discs, the left being slightly more swollen than the right.

On December 23, the following operation was performed: Primary incision showed perfect union by first intention. Wound opened throughout initial incision, dura found strongly bulging, incised over area of bulging and large amount of creamy pus escaped. Following the escape of two or three drachms of pus, there was pulsating creamy fluid, probably cerebrospinal.

For the next sixteen days there was no cerebrospinal fluid and during that time patient's condition was normal with the exception of a slight evening rise of temperature (rectal) to 100° and very slight lateral nystagmus.

On January 16, the following operation was performed under chloroform: Wound edges freshened and sutured. During this operation it was noted that the dura bulged forward through the opening in the skull to the size of a small hazel-nut. It was very elastic and very thin and there seemed to be some fluid behind it. On account of the absence of symptoms and the fact that the brain had been carefully searched on several occasions since bulging took place, this was not opened.

For two days following the last operation the patient was in good condition, but on the next day she had a rise of temperature, became very irritable, with leukocytes 21,000. Her disposition seemed to change entirely. Instead of being an obedient child, she became irritable, with violent fits of temper and crying. She complained of severe headache in the left frontal region. The following operation was then performed: Incision opened, brain incised, brain searcher introduced through the incision in dura and second abscess discovered at a somewhat deeper level than the first one occupied. Immediately following this operation the patient's disposition changed entirely and she became happy and contented. The patient made an uneventful recovery and was discharged on March 10.

This case strikes me as of considerable interest, first, because the abscess was a double one, as could be demonstrated by the encephaloscope; second, because it is a very rare thing to have a patient with deep brain abscess recover. It is also interesting to note the effect of the abscess on the child's disposition. When she came in for the second operation she was the picture of a very naughty child with a vile temper, she cried and struck at her nurse, but after the abscess was drained and immediately upon coming out of her anesthetic she showed a very sweet and lovable disposition. Since then she has been perfectly happy and contended, also obedient. At the present time she shows a slight divergent strabismus and has a slight irregularity in her gait.

I would like to remark that instead of treating these deep brain abscesses as something mysterious which might possibly be aspirated, we now look at them by means of reflected light and the brain speculum.

I would also like to show this patient with

FIBROMA OF THE NASOPHARYNX.

THIS patient with a fibroma of the nasopharynx is shown because the condition is not common and because it presents great surgical difficulties.

The patient, a boy of twelve years, was referred to this clinic because of a growth in the right cheek and difficult nasal respiration. The trouble was first noticed about the latter part of November, 1909, at which time he breathed with difficulty through his nose. He was taken to a physician who advised removal of a tumor from the nose. This was done without improvement. About ten days after the first operation, it was noticed that there was a mass in patient's right cheek. He was operated through the nose the second and third time and was then referred to this clinic February 16, 1910.

Examination revealed the right side of the nose filled with sloughing tissue, the deeper part filled with a tumor mass. The nasopharynx upon palpation showed a dense spherical tumor, apparently the size of an English walnut, its base attached to the roof of the nasopharynx on the right side. Behind this was a mass of adenoids. The right cheek showed a uniform, somewhat dense tumor growing around the lateral wall of the antrum, apparently taking its exit from the nasopharynx through the sphenomaxillary fossa.

The following operation was advised and performed February 23, 1910: Removal of the lateral portion of postnasal tumor. Incision through the mucous membrane of the lip over the presenting portion of the growth down to the capsule of the tumor. With the finger the tumor was then enucleated, with the surrounding tissues, as far as the base of the skull. This was accomplished with great difficulty, but without profuse hemorrhage. Many efforts were then made to surround this growth. with a snare and remove it by traction. Removal by this method was found impossible. An attempt was then made to sever it with curved scissors, but the growth was found to be too tough. Finally the growth was encircled with a Mathieu tonsillotome and removed partly by traction and partly by cutting through its base. Moderate hemorrhage followed and the growth was found to be completely removed up to that point at which it joined the lobe in the nasopharynx. On account of the time consumed in the operation and shock usually attending such operations, removal of the lobe in the nasopharynx was postponed. On March 4, the patient was discharged from the hospital and advised to return later for a second operation.

On March 14, the patient reentered the hospital and the following operation was performed. The greater part of the tumor was removed through the right nostril by means of a snare and biting forceps. On account of profuse hemorrhage, the operation was stopped without removing the growth entirely, it being torn out with great difficulty. On March 22, the patient was discharged from the hospital to return later for another attempt to secure the growth.

The patient returned to the hospital May 9, 1910, and the following

operation was performed-attempted removal of the remainder of the tumor which originated on the posterior end of the middle right turbinate and neighboring tissues. Attempt at removal through the nose under ether was unsuccessful on account of hemorrhage and inability to secure firm hold of the growth.

On May 16, under cocain, attempted removal of the tumor through the nose but the attempt was unsuccessful.

On May 17 the patient was discharged from the hospital and advised to return later.

On July 28, 1910, the patient returned to the hospital in good physical condition. Examination showed nasopharynx free, deeper portion of the right nostril filled with an apparently soft growth. Under this date the interior turbinate was removed, also base of the tumor which sprung from the pterygoid fossa on the right side. On July 29 patient was again discharged from the hospital to return later if he had further trouble. On January 16, the patient reentered the hospital. Examination showed the posterior half of the right nostril and nasopharynx filled with a recurrence of the growth.

On January 24, an incision two and a half inches was made through the mucous membrane of the alveolar process beginning one and onehalf inches from the median line on the right side, and extending across the median line. The soft tissues were retracted, the nose slightly elevated, and an attempt made to reach the tumor through the right nostril. This was abandoned on account of the hemorrhage. A U-shaped incision was then made through the mucous membrane of the right half of the hard palate, and an unsuccessful attempt made to remove the tumor. The incision was then carried down so as to split the soft palate to the left of the median line. This allowed of a free approach to the tumor, which was torn out by a snare with the greatest difficulty, accompanied by a profuse hemorrhage. The tumor mass was situated in the posterior half of the right inferior turbinate, partly filling the nasopharynx. It hung downward to the level of the soft palate. An attempt was then made to remove the right inferior turbinate with Strychen forceps, but on account of the extreme rubbery character of the growth and profuse hemorrhage, this was abandoned. The palate was sutured.

On February 27, 1911, the following operation was performed: The edges of the small opening through the palate were freshened. A linear incision was made just to the right of the median line through the hard and soft palates. Examination of the site of the tumor showed that a large part of the mass supposed to have been tumor was blood clot. This was removed together with a small mass of the growth that remained. The wall was apparently free to digital examination. Small fragments of growth were adherent to the wall of the sphenomaxillary fossa.

For several days previous to the operation on February 27, the patient complained of pain in the left ear. The ear was irrigated. On March 13, the patient complained of pain in the ear and tenderness in the region of the mastoid. On the 14th paracentesis was performed and the dis