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fIebical foctettee CANADIAN MEDICAL ASSOCIATION ANNUAL MEETING As previously anmounced, the Forty-eighth Annual Meetimg of the Canadian Medical Association will be held in Vancouver, B.C., July 6th, 7th, 8th, and 9th. With Dr. R. E. McKechnie as president-elect, the several committees are hard at work in the effort to make the meeting in Vancouver an unqualified success. Replies are coming ii from all parts in Canada and the United States; and from present indications, in spite of the unsettled con- dition of world politics, the meeting in July bids fair to be well up to standard. Medical men from the east are looking forward to the trip through the Canadian Rockies, which in grandeur of scenery is surpassed nowhere in the world: "A thousand Alps rolled into one. " Special round-trip rates, to be announced later, are being made to the Panama Exposition at San Francisco. Each medical man should take a vacation once a year. He owes it not only to himself, but to his patients. A programme is being prepared whereby our guests may enjoy their holiday to the full, and we all may come in touch with the highest and best ideas of our contemporaries. "As steel sharpeneth steel so doth the countenance of a man his friend." Endeavours are being successfully made to have the symposia the principal items of the programme. "Chronic arthritis" and "Chronic renal infections " have been selected and many prominent men have signified their intention of taking part in the discussions, among whom are Dr. Hlugh H. Young, of Baltimore, Dr. A. Mc- Phedran and Professor A. B. Macallum, of Toronto. More detailed anouncements will be made next month. MONTREAL MEDICO-CHIRURGICAL SOCIETY THm third regular meeting of the society was held Friday evening, November 6th, 1914, Dr. F. A. L. Lockhart, vice-presi- dent, in the chair. 262 THE CANADIAN MEDICAL LIVING CASES: 1. Two cases showing the end results in the treatment of congenital hip dislocation, by Dr. J. Appleton Nutter. The first case (N. K.) was only fourteen months of age and had not begun to walk when her condition was diagnosed by Dr. Dun- stan Gray. The x-ray shown demonstrated that the left hip was out of place. Reduction by manipulation was at once attempted under ether. It was not found especially difficult to put the hip back in place but stability of the reduced joint seemed very poor; the Lorenz or frog position was found to hold the hip more securely than any other. Many spicas had to be applied owing to their destruction by urine. Four months after the operation the hip was found to have become re-dislocated anteriorly, but it was without difficulty put back in place and treatment begun again from the begining. With successive spicas the leg was brought down to- wards the perpendicular. As I was afraid of the head escaping anteriorly, strong internal rotation was employed. For months the child, who had learned to walk while under treatment, stumped around in a spica reaching to her toes, her foot being turned direct- ly inwards. A year after the second reduction all plaster was re- moved and a flannel bandage substituted. The patient still walked with her left foot and leg twisted towards the right side but no special effort was made to overcome this. After a couple of months of flanel bandage this was removed. As you can see the child now walks perfectly, the left foot is held normally and there is no shortening. The scond patient (J. K.) was diagnosed by Dr. Charles Gurd marked right limp and much lordosis. An x-ray (which was passed when she was two years of age. She was able to walk with a around) showed the right hip out and in addition an exaggerated antiversion of the femoral neck a:nd under-development of the right side of the pelvis. The hip was reduced by manipulation in July, 1913. Stability seemed rather poor. The frog position of Lorens seemed to hold the hip more securely than any other. In this case the child was older and not so much difficulty was experienced in keeping the spica dry. In all, four plaster of Paris dressings were applied, the leg being gradually brought down to the side and at the same time twisted inwards to prevent the head of the femur from escaping anteriorly. The child walked around in her plaster one year from operation when the plaster was removed; the foot was gradually allowed to straighten itself. She now presents a perfect result, no trace of limp or shortening being evident. 2. Impaction of denture in cesophagus, by Dr. G. E. Armstrong. ASSOCIATION JOURNAL 263 The young man, who lived in the country, swallowed a plate with two teeth on it. A week later he came to Montreal with the plate firmly impacted in the upper end of the oesophagus just below the cricoid. The temperature was 1040, there was aspiration pneu- monia and he was very ill. Dr. Jamieson tried to remove the plate by the mouth. It could be seen and one could get a good grip upon it but any force which Dr. Jamieson felt justified in using would not bring it out. The man was too ill for an anaesthetic. About a week afterwards he had a pretty severe haemorrhage, in fact quite severe, losing six or eight ounces at one time. The temper- ature was falling, the pneumonia undergoing resolution and it now seemedurgent thatthe plate should be removed before he had another hamorrhage. I did an oesophagotomy under local ansthesia, which was quite satisfactory. I got down to the oesophagus just above the clavicle on the left side, drew the sterno-mastoid, the great vessels and the pneumogastric nerve outwards, pulled the omo-hyoid upwards and outwards with the retractor. The re- current laryngeal nerve lay in front and I went in behind it so that there nothing was injured. There was very little bleeding. When I got hold of the plate it was quite evident that no sufficient force could have been applied through the mouth. It was very firmly imbedded and required a good deal of manipulation to loosen it. The patient has had no hemorrhage of any account since, and the inside wound Is healed and the outside practically all healed. PATHOLOGICAL SPECIMENS: Series by Dr. L. J. Rhea. 1. Enchondroma of the finger. From the outdoor service of Dr. Tees. Patient aged sixty, for eighteen years had on one of his fingers a slowly-growing tumour which was easily enucleable and proved to be an enchondroma. It is very typical and shows the adaptability of such a tumour to its position; down the centre is a groove where it rested on the bone of the finger. 2. Brain with cerebro-spinal meningitis. Boy, aged twelve, well up to about seven hours before entering hospital, when he was taken acutely ill, and came in with definite symptoms referable to the central nervous system. Diagnosis of meningitis. Spinal canal tapped and a large quantity of fluid recovered in which pneu- mococci were present. Ears were examined for otitis media, with negative results. Child died on third day. Spinal canal was tapped several times and each tapping brought away fluid thicker and more turbid than the last. At autopsy diffuse cerebro-spinal meningitis was seen, most marked on the lateral aspect of the right cerebral hemisphere. In searching for the primay focus of in- 264 THE CANADIAN MEDICAL fection I found it in the ethnoid cells of the right side which were filled with pus and from here the pneumococci were recovered in pure culture. 3. Heart with acute endocarditis. Male, aged twenty-two, no history of rheumatism or tonsilitis; four months before entering hospital began to have symptoms referable to the heart. Since then his symptous have increased and he came to the hospital with a clinical picture of hypertrophied heart, mitral stenosis and regurgitation. The chief interest in the specimen is the size of the exudate upon the aortic valve. This has undergone calcification. In the centre of the exudate which has become calcified there is a small canal through which blood must have passed. In the mitral valve one sees a very definite aneurysm and here one notes the re- lation of the caecified exudate to this lesion in the mitral valve; it is seen that this large exudate on the aortic valve comes in direct contact with the under-surface of one leaflet of the mitral. At this point there is an area of ulceration and at the base of this ulcerated area the weakened valve has dilated, forming an aneurysm. 4. Large polyp. Dr. Lockhart removed the polyp this after- noon from a woman, aged fifty years, who complained of difficulty in micturition for the past year and during the last week had to be catheterized. The polyp has undergone extensive necrosis and is evidently infected. The woman has all the signs of a general in- fection. I show it on account of its large size and the extensive necrosis present. PAPER: Typhoid perforation, by Dr. G. E. Armstrong. DIscussIoN: Dr. F. T. Tees: During the time I was medical superintendent of the Montreal General Hospital I had, through the courtesy of Drs. Shepherd, Hutchinson, and Armstrong, the oppor- tunity of operating on seven cases of typhoid perforation, of which four recovered, or 57 per cent. Some of these cases are of special interest: One young man had a very definite history of perforation fifty hours before operation, and he was one of the fortunate. An- other patient came in from the Typhoid Emergency Hospital for operation but during the ride in the ambulance his courage failed and he insisted upon being taken home. Some hours later a tele- phone message came to the hospital that he wished to return and would undergo operation. With more humanty than judgment on our part he was admitted and the perforation closed. He died soon after. Another fatal result was in a little girl from the Hervey Institute who was operated on without delay and was apparently doing well, when another perforation occurred. Dr. Armstrong ASSOCIATION JOURNAL 265 was in the ward at the time and the patient was again operated upon but died a few days later. We found at autopsy some eleven terminal perforations. The high percentage of recoveries in this series is due not so much to the technique of the operation, which is simple, but to the early diagnosis, and this was made possible by the keenness of the house surgeons. The fact that of four cases which perforated within the hospital, three (or 75 per cent.) recovered, speaks vol- umes for the watchfulness of the internes and largely accounts for the measure of success which I am able to report. Dr. A. E. Garrow: I do not know anything in the way of acute abdomial surgery in which it is more difficult to decide to operate than in abdominal symptoms during typhoid fever. I saw a case some two or three weeks ago of Dr. D. P. Anderson's with all the symptoms of typhoid perforation, patient toxic, acute onset of abdominal pain, localization of pain to the lower abdomninal zone followed by distension and more or less rigidity, with sudden drop of temperature and apparent disappearance of liver diilness. These all occurred before I saw the case. We decided to wait for a day or two and the symptoms subsided. The patient was kept under ob- servation and improvement generally took place and he was placed under medical care in the Royal Victoria Hospital. Subsequently severe hamorrhages occured with terminal symptoms, the patient dying with acute abdominal pain and either actual or threatened perforation had taken place. I do not think many surgeons make the mistake of letting a perforation go, but I think that every sur- geon who has had much experience with this has opened the abdomen and found no perforation. I have opened twice to find nothing but a large quantity of yellow turbid fluid, usually great enlargement of the glands in the lower portion of the mesentery and numerous flake-like patches over numerous ulcers in the lower part of the bowel. This was done under local anaesthesia and did not seem to militate against a comparatively rapid recovery, in fact there was marked improvement of the condition. As Dr. Armstrong has said it is extremely difficult to give a symptom-complex in any particular case which is pathognomonic of perforation. Dr. D. P. Anderson: The case of mine to which Dr. Garrow referred was particularly interesting. It demonstrated the fre- quency with which you get cases without any suggestion of perfor- ation. This case I remember to have visited about half past twelve, and as I do in all typhoid cases, examined very carefully along the course of the ileum for evidence of tenderness; there was not the 266 266 THE CANADIAN MEDICAL slightest evidence of anything having gone wrong and at half past two the patient had all the symptoms that Dr. Garrow has depicted. Dr. L. J. Rhea: One point which Dr. Armstrong referred to is of interest, the acute peritonitis in typhoid without perforation. I once showed before this Society the mesenteric nodes from two cases of typhoid in both of which there was acute suppuration. In a third case, operated on for acute peritonitis, it was found that one of the mesenteric nodes had ruptured and the adjacent nodes were quite markedly necrotic. Cultures from the fluid in the abdominal cavity showed typhoid bacillus in pure culture. Dr. A. G. Morphy: I had a case of a man in the Lachine General Hospital who in the third week of typhoid fever developed a sudden pain in the abdomen. I saw him a short time after- wards and found the abdomen rigid. We found a perforation of Meckel's diverticulum, which was sewed up, and the mian made a good recovery. Dr. C. F. Martin: Having had the good fortune of seeing pa- tients with perforation and having been able to observe what the surgeons have done, I was much interested in Dr. Armstrong's paper. I wonder if perhaps his opiniion concerning the sudden onset of pain as associated with tenderness corresponding with the site of the pain, bears very much weight in the diagnosis. We have laid a good deal of stress in the course of typhoid upon the coincidence of location of sudden onset of localised pain and the corresponding tenderness, as of a good deal of importance; on that symptom-com- plex alone we would ask the surgeon to operate. A year or two ago I came across a similar case to which Dr. Rhea refers and a year or two later we had cases simultaneously in the two hospitals of the same nature-localised pain in the right iliac fossa, with ten- derness. The cases were operated upon in each institution and large and ha'morrhagic glands were found around the ileum, but no perforation. Both cases were closed up and did well. Leuco- cytosis was present, in one 14,000 and in the other 17,000, so we thought we were all the more justified in having the abdomen opened. Dr. Armstrong said little or nothing about the leucocytic count in suspected perforation cases; he probably has little faith in the efficacy of that means of telling a perforation. Some years ago I got Dr. Russel to observe this count in a great number of cases and he found the variation so great that it was not worthy of consideration as a decisive criterion, and although we still take the blood count we do not lay too much stress on it for diagnosis. ASSOCIATION JOURNAL 2672 What Dr. Armstrong said about the rectal examination appealed to me very much, as so often we have confirmed our diagnosis by this means. If there is abdominal pain low down and tenderness in the rectum we would feel strongly like recommending that the abdomen be opened, so useful is this as a sign in typhoid perforation. Dr. D. F. Gurd: I have seen another means of diagnosis which has helped in obscure cases and that is the use of the stetho- scope and getting a localized rAle from the abdomen. Dr. J. Alex. Hutchison: I have nothing particular to offer in the way of discussion but would say that all house surgeons should be on guard for perforation in typhoid fever. Within this week one of our men diagnosed a perforation in less than an hour but unfor- tunately the man died within an hour from a second perforation. Dr. G. E. Armstrong: Two or three points have been brought out in the discussion; first, the association of pain and tenderness. I think it can be stated that as a general rule the tenderness is over the lesion. The maximum point of tenderness is over the lesion in all perforative conditions whejher the gall-bladder, stomach, in- testines, appendix, etc., and when there is pain and no tenderness then certainly a rectal examination should be made. It is well to make it in all cases and sometimes you will get definite tendernes where you fail to find it from ordinary pressure over the abdominal wall. There are a few cases which do not follow that rule, but they are rare. In 50 per cent. the tendernoss is noted as general. In appendix cases pain may be referred as over the umbilical region in the neighbourhood of the solar plexus and orly a little later the patient will refer his pain definitely to the right lower quadrant and occasionally I have seen the pain complained of definitely on the left side while the ruptured appendix was on the right. In the same way you may have pain complained of in the one side where there is a stone of the kindey on the opposite side. The leucocy- tosis I have practically given up as a diagnostic sign in typhoid perforation. A few years ago we worked at it assiduously and we found it unreliable; it was present to a marked degree without per- foration and certainly in a good number of our perforations leuco- cytosis was not perceptible so I do not pay much attention to this. As to second perforations; these sometimes can be closed. I had one patient who recovered after the close of a second perforation, another case did very well till the twenty-third day when he had a third perforation which was in the old wound; we could see it in the intestine as it dropped right out and a perforation took place within the abdomen and carried him off. Two or three days 268 THE CANADIAN MEDICAL ago I had a case in hospital with very definite symptoms of per- foration; I saw him within a very short time, the symptoms were quite clear and he was brought to the operating room at once. As soon as the abdomen was opened, out came a tremendous amount of gas and the abdomen flattened right down. I pulled out the lower end of the ileum but could find nothing there; I examined the caecum, went back to the intestine and followed it right through to the transverse mesocolon; there were some evidences of trouble around the jejunum but I could find no perforation. I examined the caecuxn, ascending colon, transverse, sigmnoid, rectum-no per- foration. I closed the abdomen and returned the patient to the ward. At autopsy Dr. Oertel found the perforation in the splenic flexure just under the diaphragm. Another remarkable thing about this was that there was no soiling of the peritoneal cavity. This is one of the rare situations for a perforation; as a rule you can count on it being within the terminal fourteen inches of the ileumn. CA8E REPORT: Calculus nephritis with bilateral occlusion of ureters, by Drs. A. E. Garrow and H. Oertel. Patient a young woman of twenty-nine; good health until March 10th, 1913, when she sustained a fracture of the thigh which was treated in the West and for which she remained a long time in bed. She was perfectly healthy except for this fracture until Christmas when she experienced slight, dull, aching pains in the right side for ten or twelve days. This-recurred in March for two of three days, and again in August; it was felt in the right costal margin and was of a dull aching character without radiation; in September she passed several small stones. At this time while in hospital she had suppression of urine which lasted three days. So far as we could learn at no time did she have bladder disturbance or pain in the left loin. She returned to hospital on October 10th with a history of sudden pain in right side radiating to groin. She had never passed any blood, but since this last attack there had been more or less daily vomiting. She was unable to retain food and we began rectal feeding. The quantity of urine passed varied from twenty-six ounces on the second day after coming in, through five, seven, eight, nine, ten, fourteen and nine ounces. There was a distinct trace of albumin, a few red blood cells and, in addition to granular casts, a relative and total diminution in the quantity of urea passed each eay. She was bright, skin was clear, no cedema of limbs or eyelids. Temperature subnormal throughout; there was no diarrhoea, no bladder disturbance whatever. She had a foul, foetid breath, bright red tongue and wanted constantly to ASSOCIATION JOURNAL 269 drink, and no sooner would she have it than it was rejected again. An attempt was made to tide her over this calculus uriemia, to take advantage of the compensatory function of the skin, hdt packs and hot baths, salt solution intravenously, but there was no perspiration. After each of the attacks we had a slight improvement in the quan- tity of urine passed and some improvement in the vomiting. The patient was bright for the first six or seven days but for the last three was rather dull; her condition seemed to be improving on the day she died and for fourteen hours there had been no vomiting. In the morning of the day she died she became very drowsy, breath- ing laboured, pulse weak throughout became imperceptible, and she died apparently from cardiac failure. The object of our treat- ment had been to tide her over what was apparently a condition of calculus uramia sufficiently to open one or other kidney. She had never at any time complained of symptoms in the left side, all were in the right, and I would have taken it for granted that this was the functioning kidney; it was my intention under local an- msthesia to have done either a single or a double nephrectomy and, if further improvement had taken place, to remove the stones present. She was not catheterized nor was the bladder examined, nothing was done to militate against the very serious condition from which she suffered on entering the hospital. Dr. H. Oertel: Very little has to be added to this case except to demonstrate the specimen. The whole urinary system is the seat of very extensive stone formation, which involves not only the kidney but the pelvis and the markedly dilated calices, but extends down through the ureter into the bladder which also contains several large stones. It is interesting to note that occlusion has occurred at the origin of both ureters immediately below their insertion into the pelvis of the kidney. The character of the stones is that of earthy phosphates. Undoubtedly the condition has existed for some time inasmuch as one can observe that the mucous membrane is markedly thick throughout and that the pelvis is markedly dilated and a hydro-nephrosis exists. The calices extend far up into the medulla of the kidney. In addition to a subacute inflam- matory lesion there has occurred a more recent acute sero-purulent exacerbation and this involves in an ascending fashion the kidney substance so as to produce a rather typical diffuse ascending pyelonephritis. This is particularly marked in the medulla and involves in patches the cortex. While the cortex has remained comparatively free from the purulent exudate it shows very marked general oedematous swelling with degeneration of the epithelial 270 THE CANADIAN MEDICAL cells and gradual involvement of the kidney parenchyma of the cortex in the inflammatory exudate. Any operative interference in this state was of course out of the question and it is doubtful whether recovery could ever have taken place sufficiently to admit of any operative interference in the future for the extensive stone formation involved the whole urinary system.

TORONTO ACADEMY OF MEDICINE NOVEMBER MEETING OF SPECIAL SECTION CASES IN PRACTICE AND SPECIMENS PRESENTED. By Dr. Geoffrey Boyd: 1. Multiple exostoses removed from the middle ear by simple mastoid operation. 2. Pipe stem removed from the pharynx of an elderly man. Had been mi this position for a month. Associated with some loss of motion and pain in the arm of the same side, suggesting pressure on the origin of the brachial plexus. Dr. H. J. Hamilton discussed this case. By Dr. Colin Campbell: Cyst in the anterior chamber, shewing two lobules. There is a history of a wound some years ago, but this began to cause trouble only this summer; it has enlarged con- siderably in the last month, and Dr. Campbell considered it prob- ably due to inclusion of some epithelial cells at the time of the perforating corneal wound. To be reported later. By Dr. Edmund Boyd : Polyp. in a child of six years with a long pedicle appearing to come from the antrum. A chief interest in the case is the youth of the patient. At present Dr. Boyd is undecided as to the method to be pursued for its removal, but leans to simple snaring and a close watch for return. Should the latter happen he would consider it proof of its antral origin, and would probably open the antrum. By Dr. Trebilcock: Some cases of wounded eyeball: 1. Punc- tured wound in the inner cilary region caused by portion of a large split pin. Loss of vitreous, but after a smart reaction a good recovery. At present a mass protruding into the vitreous at site of wound, and a lens becoming cataractous. 2. Punctured wound of the cornea. Inverted U-shaped, with the angles going just to the limbus. Caused by large shears. ASSOCIATION JOURNAL 271 Wound closed well, but after two months began to leak slightly at both angles. Eye quite quiet at present. 3. Punctured wound of cornea, done with large screw-driver. Traverses the upper outer third of the cornea to the limbus at both angles. Wound closed for nine weeks but eye still irritable and likely to give trouble. 4. Punctured wound of the sclera; piece of nickel ore 10 mm. x 5 mm. x 3 mm. removed from the vitreous after being there ten days. Removed with forceps through a new wound made at the site of x-ray localization. Result very good. Vision shadows. 5. Punctured wound of sclera. Small particle of steel removed from vitreous with giant magnet through a new opening. X-ray used to localize. Result good. 6. Punctured wound of sclera. Metal seen shinmering m vitreous with ophthalmoscope, and localized. Removed with small magnet through new opening made directly over present position. Steel in eye thirty hours. Result good. Dr. Durnham read a report of his successful use of Bardsley's punch in a case of acute glaucoma. The classical signs were all present, but the conjuctiva was brawny and stiff and the anterior chamber very shallow. He considered it an unfavourable case for an ordinary iridectomy on account of the difflculty, and the brawny conjuctiva made the management of the flap very difficult in Elliott's method. He had succeeded admirably with Bardsley's scleral punch which entered the chamber easily, and cut and re moved the disc at the limbus quickly and easily. He had also done an iridectomy, but the iris had remained so nicely in its place and plane that another time, under such circumstances, he thought he would omit the iridectomy. He expressed himself as extremely gratified with the outcome of the use of this little scleral punch. Dr. O'Connor detailed the course of three cases of mastoid abscess treated by operation and blood clot. Two had done well, and the third had broken down. He considered this a satisfactory method in selected cases, especially where there is a mono-bacilliary infection. He said they did not as a rule do well where the in- fection was multi-bacilliary. Drs. Biggs and Edmund Boyd dis- cussed this question. Dr. Wishart, temporary chairman; Drs. Davies, Reeve, G. Boyd, Maclennan, C. Campbell, Bell, Trebilcock, and others, took part in the discussions. 272 THE CANADIAN MEDICAL Discussion of the question of eyeball wounds was left over on account of the full programme and the late hour. Dr. Gilbert Royce was proposed as chairman of the section in the absence at the seat of war of Dr. Goldsmith. This recommend- ation was sent on to the council.

MEETING OF DECEMBER 14TH, 1914 CASES PRESENTED. Dr. O'Conor: A man, aged thirty-six, who had suffered from cough for several years before coming to Canada seven years ago. Had night sweats at times and a husky voice. Since coming here the general condition has been fair so that he has been able to attend to his work of driving a team with intermission. For a year and a half he has had some pain in the throat on movement, as in swallowing, slight but always referred to the left side at the level of the upper border of the thyroid cartilage. Also a sensation of lump in the throat and a desire to swallow it. Slight loss of strength, a cough, and a husky voice. Personal and family history lend no aid. The examination of the throat revealed a thickened, cloven, epiglottis folded on itself, from side to side, and front to back, so that it hid the picture of the larynx. However, the arytenoids were seen to be swollen and cedematous, as were the ventricular bands. The chest was found to show evidence of involvement of both apices, and tubercle bacilli found in the sputum. A section of the thickened epiglottis shows giant cells. Dr. Royce spoke of the pain on movement of the larynx; of the loss of strength as being slight for such extensive lesions, and of the normal temperature. Dr. E. Boyd remarked on the marked symmetry of the lesion, and asked if the laxity of such an epiglottis would be a factor in a tuberculous infection thereof. Dr. McLennan said it was strange that there had been so little loss of vitality in so extensive disease. Dr. Wishart detailed Richard Lake's idea that the infection of laryngeal parts was almost always secondary to chest disease and due to the definite lodgement there of bacilli from the sputum. He wondered if the folded shape of this epiglottis was primary and a causative factor, or secondary to involvement. Dr. Royce described the turban shape of the epiglottis as he had first seen it but could not answer Dr. Wishart's question. He thought that part to the right of the cleft had shown some abrasion, and spoke of his method of painting such suspected abrasions with ASSOCIATION JOURNAL 273 weak silver to show them up brilliantly against the surounding pink or red background; however, the whole epiglottis in this case was too white to use this method. He considered there was also slight involvement of some intralaryngeal tissues. Dr. Wishart showed a rhinolith removed from the nose. The patient was a woman of seventy-two years, who had suffered from a severe neuralgia of the left side of the nose and the gum. Exanin- ation of the nose showed a mass lying on the floor against the sep- tum, about an inch and a quarter back. A part of the mass had been removed four months previously. The present mass was too large to remove anteriorly but was successfully brought through the posterior nares. The rhinolith was about one inch by three- quarters by five-eighths, and lay in a hollow in the floor of the nose. At first he thought it might be a sequestrum, but the smooth bed precluded that. Careful examination revealed no sure origin for the mass. The neuralgia had not been relieved. Dr. Angus Campbell described a somewhat similar case. A rhinolith was removed from the nose of a young woman over twenty, and in the centre was found a piece of slate pencil which she said she had pushed there when a child. Dr. Wishart then presented the following case of suppurative middle ear with mastoid involvement, simple operation with blood clot. T. E., aged twenty three, male, suffered from deafness of the right ear, and discharge for twelve months, beginning without pain, and also from discharge of the left ear for a number of years, with strong odour. Of late, there has been pain in the right mas- toid, so severe as to necessitate remaining away from work. On examination, hearing, right ear, 20/60, small perforation in the anterior inferior quadrant, slight moisture, mastoid tender, but no swelling; left ear, hearing contact, membrane absent, except in the attic, remains of ossicles, stinking discharge, and granular internal wall. When seen first, six months ago, regular treatment of the ears with intra-tympanic syringing and alcohol drops ordered. There was no improvement in any of the symptoms, and operation was decided upon. Right ear mastoid opened and curetted, but dura mater not exposed. The aditus was thoroughly cleared and the middle ear syringed. The aditus was then plugged with iodoform powder, the cavity filled with blood clot, and the incision entirely closed by sutures. In the left ear remains of the ossicles were re- 274 THE CANADIAN MEDICAL moved, the middle ear curetted, and the eustachian tube curetted with Yankauer's instruments. The wound of the right ear was healed within a week, the canal was mopped out twice daily, and drops of alcohol, acid boracic and oichloride instilled. The left ear was syringed twice daily for a few days, after which it was mopped only and dry boric acid blown in. The case is shown to demonstrate the conservative method of treating the right ear, where the hearing was fair, and where any interference with the middle ear was very inadvisable. The patient has been in hospital only two weeks, and is now ready for discharge. Dr. Crosby showed a case with a small mass in the upper part of the vitreous having an indefinitely serrated border. There had been some iritis, and pain; slight injection. No sign of the mass appeared from outside. It had not the definite shape one would expect in a malignant involvement of the ciary body, yet he thought it had its origin there. Dr. Reeve said it looked like an indefinite opacity in the equator of the lens, but he would like to see it in a month. Dr. Maclennan thought it arose from the ciliary region and might be dangerous. Dr. Trebilcock said it was very shallow, inasmuch as one could almost get behind it with the ophthalmoscope used very obliquely. It must be a slight exudation associated with the iritis which had been present, but was not now. The inflammatory process may have been more a cyclitis, or more at the irit root. He did not think it looked like a sarcoma, but would ask to have the case shown again. Dr. Trebilcock showed: 1. A case of keratitis in a boy of four- teen. Said to have come oti after attendance at a wheat threshing two months ago. There were infiltrations in all the layers of the cornea, with a broad leash of vessels coming over from the upper, outer quadrant. The grey patches were discreet, and the rest of the corneal rim was clear cut. The case did not appear to be spe- cific in the local signs, nor had the boy the ear-marks of congenital syphilis. 2. A boy of four years who had his eye cut with a piece of glas early in February last. Sitting behind a window the latter had been broken with a thrown snow-ball. The upper lid had been cut and the sclerotic pierced in the upper, inner quadrant far back. Vitreous was protruding but no blood in the chamber. The edges of the wound were carefully probed, but no glass felt. The pro- ASSOCIATION JOURNAL 275 truding vitreous was removed and the wound sewn. The immediate recovery was good. For three months the boy saw as well as before with the injured eye, then the outer quadrant of the iris seemed to recede, making an irregular pupil; and early in the summer there developed a hyphama. The latter persisted all fall, and was associated with slight circum-corneal injection, and photophobia. In the last month, under dionin, the anterior chamber has cleared and the injection become markedly less. The pupil is irregular in shape, but no synechie. No fundus reflex to be seen. The tension slightly minus, but the eye not tender. Is the eye a safe one to leave? Dr. Reeve spoke of work done by Browning, making a differ- ential leucocyte count, an increase of monos meaning the coming of sympathetic; but the test had been misleading in one of his cases. He thought it safe to temporize in this case. Dr. Maclennan thought the eye must come in the class of dangerous ones and sooner or later would come to enucleation; the sooner the better. There might be a spicule of glass in the eye, but if so it was the safest kind of a foreign body to have there.

ONTARIO MEDICAL ASSOCIATION THE following is the provisional programme for the annual meeting of the Ontario Medical Association: Tuesday, May 25th: Registration. Wednesday, May 26th: Morning-Registration. Afternoon-Business, General Session. Evening-General Session, President's Address, Address in Medicine. Thursday, May 27th: Morning-Sectional Meetings. Afternoon-General Session, Businews Meeting, Address in Surgery. Evening-General Session, Symposium on Heart. Friday, May 28th: Morning-Sectional Meetings. Afternoon-General Session, Bumsness Meeting. 276 THE CANADIAN MEDICAL ASSOCIATION JOURNAL. (1ebical ;octetieza CANADIAN MEDICAL ASSOCIATION:-President-Dr. Murray MacLaren. SL John, N.B. P d elect-Dr. R. E. MeKochnic, Vancouver. Secretary-treasurer-Dr. W. W. Franci, 838 Uniby Street, Montreal. Annual Meeting, Vancouver, B.C., July 6th to 9th, 1915. ACADEMY OF MEDICINE, TORONTO:-Presdent-Dr. H. B. Anderson. Scretary-Dr. J. H. Elot. ALBERTA MEDICAL ASSOCIATION:-Preodent-Dr. R. G. Brett, Banf. Seotetay-Dr. F. C. Clar Calgary. ASSOCIATION OF MEDICAL OFFICERS OF THE MILITIA:-President-Lt.-Colonel A. T. Shllllngtoa, A.M.C., Ottawa. Secretary-Captain T. H. Leggtt, A.M.C., Ottawa. BRITISH COLUMBIA MEDICAL ASOOCIATION:-Preddent-Dr. J. Glen Campbell, Vanoouver. Ses tary-Dr. H. W. Riggs, Vancouver. CALGARY MEDICAL SOCIETY:-President-Dr. G. John. Secretary-Dr. J. L Allen. CANADIAN A8SOCIATION FOR THE PREVENTION OF TUBERCULOSIS.-Prpeddent-Dr. J. G. Adai, Montreal. becetary-Dr. George D. Porter, Ottawa. CANADIAN HOSPITAL A88OCIATION:-President-Dr. H. A. Boyce, Belleville. Secretary-Dr. J. N. E. Brown, Toronto. CANADIAN PUBLIC HEALTH ASSOCIATION:-Presddent-Dr. C. A. Hodgette. General SeoretrY- Major-Lorne Drum. CENTRAL SOUTHERN ALBERTA MEDICAL SOCIETY.-President-Dr. J. 5. Murray, Okotoks. Seore. tary-treasurer-Dr. G. E. Learmouth, High River. COLCHESTER-RANTS MEDICAL SOCIETY:-President-Dr. J. W. T. Patton, Truro. ScoretarDr. HI. V. Kent. Truro. EDMONTON MEDICAL SOCIETY:-President-Dr. J. 8. Wright. eretry-treaurer-Dr. Jamineon. ELGIN COUNTY MEDICAL ASSOCIATION:-President-Dr. Frederick MoEwen, Aylmer. Ont. Secretary- Treasurer-Dr. A. B. Riddell, Bayham. FRASER VALLEY MEDICAL SOCIETY.-President-Dr. DeWolfe Smith. Secretarr-Dr. D. F. Carwen. HALIFAX MEDICAL ASSOCIATION.-President-Dr. Kirkpatrick. Secretary-Dr. MacIntosh. HAMILTON MEDICAL ASSOCIATION-President-Dr. John Y. Parry. Corresponding Seoretary-Dr. P. D. MacFarlane. Recording Secretary-Dr. 0. W. Niemier. HIIURON MEDICAL ASSOCIATION-President-Dr. Kennedy. Secretary-Treasurer-Dr. Redmond. KINGSTON MEDICAL AND SURGICAL SOCIETY:-Presdent-Dr. W. G. Anglin. Secretary-Dr. W. T. Connell. Treasurer-Dr. G. W. Mylks. LAMBTON COUNTY MEDICAL ASSOCIATION.-President-Dr. R. M. Calder, Petrolea. Secretary- Treasurer-Dr. J. E. Kidd, Wyoming LONDON MEDICAL ASSOCIATION:-President-Dr. C. H. Reason, 538 Dundas Street. Secretary. tressurer-Dr. L. S. Holmes, 260 Hamilton Road. LUNENBURG-QUEEN'S MEDICAL SOCIETY:-President-Dr. J. W. Smith. Liverpool. Secretary- Dr. L. T. W. Penney, Lunenburg. MANITOBA MEDICAL ASSOCIATION:-President-Dr. H. A. Gordon, Portage La Prairie. Secretary- Dr. R. B. Mitchell, Wmin MEDICINE HAT MEDICAL O1t-ITY:-PreidenDr. W. M. Thomas. VicePresdent-Dr. W. H. MacDonald. Secretary-treasurer-Dr. A. V. Brown. MONTREAL MEDICO-CHIRURGICAL SOCIETY:-President-Dr. D. F. Gurd. Secretary-Dr. Hanford McKee MOOSE JAW MEDICAL SOCIETY.-Presldent-Dr. Geo. P. Bawden. Secretary-treasurer-Dr. C. 0. Sutherland. NEW BRUNSWICK MEDICAL SOCIETY:-President-G. Clowes Van Wart, Fredoricton. Secretary- J. 8. Bentley. NIAGARA DISTRICT MEDICAL ASSOCIATION:-President-Dr. E. T. Kellam, Niagra Falls. Scee tary-Dr. G. M. Davis, Welland. NOVA SCOTIA MEDICAL SOCIETY-President-Dr. G. E. DeWitt. Secretary-Dr. J. R. Corston. ONTARIO MEDICAL ASSOCIATION:-Preuldent-Dr. D. Gibb Wishart, Toronto. Secrtary-Dr. F. A. Clarkson, 421 Bloor Street West, Toronto. Local Secretary-Dr. J. B. Mann, Peterborough. Annual Meeting, Peterborough, May, 1915. OTTAWA MEDICO-CHIRURGICAL SOCIETY:-President-Dr. J. F. Argue. Secretary-Dr. R. K. Paterson. Treasurer-Dr. A. S. McElroy. OTTAWA MEDICAL SOCIETY:-President-Dr. Charles W. Gorrell. Secretary-Dr. A. MacLsa, Treasurer-Dr. Harold Alford. PERTH MEDICAL ASSOCIATION:-President-Dr. A. F. MoKensie, Monkton. Secretary-treasurer-Dr. F. J. R. Forster, Stratford. PERTH COUNTY MEDICAL ASSOCIATION:-President-Dr. C. F. Smith, St. Mary's. Secretary- treasurer-Dr. F. J. R. Forster, Stratford. PETERBORO MEDICAL ASSOCIATION:-President-Dr. E. A. Hammond. Secretary-Dr. J. B. Mann. PICTOU COUNTY MEDICAL ASSOCIATION:-President-Dr. C. 8. Elliot. Stellarton. Secretary-Dr. John Bell, New Glasgow. PRINCE EDWARD ISLAND MEDICAL ASSOCIATION:-President-Dr. A. A. MacDonald. Secretary- Dr. W. J. MaoMillan, Charlottetown. REGINA MEDICAL SOCIETY:-President,-Dr. Gorrell. Secretary-Dr. Dakin. ST. JOHN MEDICAL SOCIETY:.-President-Dr. D. Malcolm. Secretary-Dr. F. P. Dunlop. ST. THIOMAS MEDICAL ASSOCIATION:-President-Dr. D. L. Ewin. Secretary-treasurer-Dr. James A. Campbell SABKATCHEWAN MEDICAL ASSOCIATION.-President-Dr. G. P. Bowden. Secretary-Dr. C. 0. Sutherland, Moose Jaw. Annual meeting, Moose Jaw, July 27th, 1915 SASKATOON MEDICAL ASSOCIATION.-President-Dr. T. W. Walker. Secretary-Dr. J. T. Maockay. SWIFT CURRENT DISTRICT MEDICAL ASSOCIATION:-President-Dr. Graham. Secretary-treasuror -Dr. Hughes. TEHUNDER BAY MEDICAL SOCIETY:-President-Dr. R. J. Manion. VicePresident-Dr. Eakins. Secre tary-treasurer-Dr. J. G. Hunt. VALLEY MEDICAL SOCIETY:-President-Dr. M. E. Armstrong, Bridgetown. Secretary-Dr. T. M. Mae- Kinnon, Berwick, N.S. VANCOUVER MEDICAL ASSOCIATION:-President-Dr. W. D. Keith. Secretary-Dr. J. H. MacDermo WEST ELGIN MEDICAL SOCIETY:-President-Dr. Crane, Wallacetown. Vicpresident-Dr. Web*WP, West Lorne. Secretary-treasurer-Dr. Smith, Fingal. WINNIPEG MEDICAL SOCIETY.-Preeident-Dr. James MoKenty. Secretary-Dr. D. F. McIntyre.