George E. Shambaugh

THE PROBLEM OF GRADUATE INSTRUCTION IN CLINICAL MEDICINE

The demands for graduate instruction in clinical medicine come from men engaged in general practice who desire to piece out the shortcomings in undergraduate preparation or who wish to keep abreast of more recent advances, and from those graduates in medicine who desire preparation for special practice. These are two quite distinct problems in medical education. The one calling for short review courses for men engaged in general practice has been met in part though not in a very satisfactory manner by work offered in postgraduate schools. The other, that of preparing men for special practice, has in this country received very little serious attention, and with the increasing tendency to specialization constitutes an outstanding problem in medical education. Men seeking preparation for special practice have usually had to rely on short, intensive courses suitable especially as review work for those in general practice, with the result that the special

CHRONIC OBSTRUCTIVE MIDDLE-EAR DEAFNESS

A great deal of confusion persists among practicing otologists regarding the diagnosis and especially the prognosis of those diseases of the middle ear which produce deafness as the result of obstruction in the sound-conducting mechanism. There is, perhaps, no form of ear trouble regarding the diagnosis and prognosis of which the patient has more just grounds for complaint than these cases of obstructive middle-ear deafness. The difficulty in diagnosing these conditions is sometimes increased by the combination of two distinctly separate processes; such, for example, as the development in middle life of a bony fixation of the stapes in a case in which there has been in childhood a long-standing middle-ear inflammation. As regards the prognosis of obstructive middle-ear deafness, confusion has often been increased because of the effort to apply in the classification of these cases terms which a more recent study of pathology have rendered more or less

SOME IMPORTANT SURGICAL RELATIONS OF THE TEMPORAL BONE.

The operation on the ear which contemplates a complete exenteration of all the tympano-mastoid cavities is rightly considered as a difficult surgical procedure. In the first place, a large number of vitally important structures are crowded together in the small field of operation. Any one of these may be easily injured if the operator is not thoroughly acquainted with their exact location. In the second place, the cavities of the tympanum and mastoid, which must be opened and thoroughly cleaned out if these operations are to be successful, are extremely complicated and their character varies widely in different individuals. It is, therefore, a matter of first importance that the otologist who would undertake these operations on the ear should first master the details of the surgical relations of this region, which in many respects is the most difficult of any part in human anatomy. A thorough knowledge of these difficult