29. Dr. D. W. Vanderburgh, late of Fall River, Mass., died on August Dr. J. Miller Hinson's sudden death in Saratoga, N. Y., which occurred early in October, came as a shock and surprise to his Boston colleagues. An obituary will appear in the December issue of the Gazette. Dr. John F. Worcester has removed from Massachusetts to Oregon, and has given up the practice of medicine for fruit farming. Dr. David L. Martin, class of 1909, B. U. S. M., has resigned his position as house physician at the Emerson Hospital and has located at 4 Rosedale street, Dorchester, In the October number of the Gazette it was stated that Dr. Geo. N. Lapham had associated himself with Dr. D. P. Butler in the conduct of the Rutland Cottages. This we learn to have been an error, as Dr. Lapham has started an independent practice in Rutland, where he gives particular attention to tuberculosis and its allied conditions. Dr. Irving H. Kiesling, class of 1904, for several years in service at Fergus Falls (Minn.) Insane Hospital, is now at Rood Hospital, Hibbing, Minn. Dr. H. R. Arndt, the newly elected field secretary of the American Institute, has already shown most commendable activity in his inception of the work. He has made quite an extensive tour through the Northwest, visiting the State society meetings of Washington, Oregon and Colorado. He has also been a guest of the Chicago Society, of the Pennsylvania Society and attended the opening exercises of the Hahnemann Medical College of Philadelphia. Dr. Samuel Lambert, Dean of the College of Physicians & Surgeons, New York, in his annual report to Columbia University strongly urges the need of a hospital in immediate connection with the college in order to more satisfactorily carry out the work of instruction to the upper classes. He expresses his opinion that the sum of six million dollars is necessary for its erection and suitable endowment. Dr. John B. Shoemaker, who has for years held the position of Professor of Materia Medica, Pharmacy and Therapeutics, and Clinical Professor of Medicine of Skin Diseases in the Medico-Chirurgical College, Philadelphia, died October 11. Dr. Shoemaker was well known by the entire medical profession, largely on account of his voluminous writings upon his specialty. The report of the Michigan State Board of Registration in Medicine for June shows that the highest percentage was obtained by a graduate of the Chicago Homeopathic Medical College; not only so, but this graduate was a member of the class of 1878. The Gazette would be very giad to learn the name of such a distinguished graduate who, after thirty-two years away from the medical school, has been able to make such an enviable record. Pursuant to instructions received at the California meeting of the Institute Dr. James Ward appointed the following committee upon college endowments: For New England, J. P. Sutherland; for New York, R. S. Copeland; for Pennsylvania, W. B. Van Lennep; for Michigan, W. B. Hinsdale; for Ohio, George H. Quay; for Illinois, C. E. Carke; for Iowa, George Royal; for California, J. E. Ward. Tuberculosis, in its various forms, is now engaging the best. thought of the medical profession in every civilized country in the world. The so-called "crusade" against the spread and the ravages of this disease is one of the glories of our twentieth century progress. From the side of the profession and the laity alike. have arisen men and women of the noblest type, who have thrown into this struggle their strength, wealth, wisdom and experience. And the efforts of these practical workers in the field have been wonderfully seconded and most efficiently directed by the labors of the men of science pursuing their investigations in the laboratory. Never before has the nature of this disease, the mode of its transmission and the method of its prevention and its treatment been so well understood as now. To this general knowledge the specialist can add some further details regarding the action of the disease upon individual organs throughout the system-details which may be both of use and of interest to general practitioners of medicine and to specialists in other departments than his own. Let us then consider the effects of tuberculosis upon the organ of hearing-upon whose integrity so much of the usefulness and the satisfaction of living depends. The typical development of a case of tuberculosis of the ear proceeds as follows. The patient, probably far advanced in pulmonary consumption, is annoyed for a few days by a feeling of fullness in the ear, with some tinnitus and reverberation of his own voice in speaking, and some sense of deafness upon the side affected. Then there will appear, to his surprise, moisture in the ear and a discharge is soon established, which consists at first of a rather bland muco-serous fluid, but later becomes thicker, distinctly purulent and offensive if thorough cleansing is neglected. Usually no great concern is felt by the patient, or his family, at this earlier stage of the invasion, for the reason that throughout the whole development no pain whatever has been felt. In no other form of aural disease will a suppuration be thus estab lished without pain which is violent and prolonged-pain which is at once the central feature of the disease. If the patient consults at this time a physician who is accustomed to specular examination of the ear, he will find the drumhead exhibiting, in all probability, two or three rather large perforations, instead of one perforation, as would be expected in other suppurative states. Had the specular examination been made some days before, when the attention of the patient was first called to the fullness in the ear, he would have seen the drumhead exhibiting several yellowish-red spots which later became somewhat granular in appearance and still later showed areas of minute perforations, which coalesced to form the larger perforations, two or three in number, which have just been mentioned. Upon succeeding calls of the patient these larger perforations will be seen to have united and almost the entire drumhead to have been destroyed. The mucous membrane lining the cavity of the middle ear will be seen to be involved, with fine granulation, ulceration, cheesy degeneration and carious destruction of adjacent osseous tissue, but not with the development of large granulation masses or of polypi, as might be expected in ordinary suppurative attacks of the middle ear, which also show less active involvement of the bony structure. Should this case be neglected, from this time on, and the progress of the aural involvement be unchecked by local drainage, cleansing and disinfection, the most serious results may ensue-involving the loss of the ossicular chain with marked deafness; the invasion of the labyrinth with total deafness, or with distressing disturbance of equilibrium; erosion of the carotid artery or jugular vein with fatal hemorrhage; paralysis of the facial nerve; the formation of extensive sequestra or large areas of softened and crumbling bone, and even meningeal involvement or other intercranial complications, although the pulmonary condition usually first claims the life of the patient. Through all this destructive course, however, the almost total absence of pain remains the most marked and characteristic feature of the disease-distinguishing it at once from similar destructive processes dependent upon other causes. If a search is made in this typical case for the tubercle bacillus, to place the diagnosis beyond question, it may or may not be found. Something depends upon the part of the diseased area from which the secretion for examination is taken. It is well understood that the bacillus is rarely found in pus from tubercular caries. It is most likely to be found, therefore, in secretions, or portions of granular tissue, taken at a point removed from the carious centre. Even then, in many undoubtedly tubercular cases, the tubercle bacillus cannot be demonstrated. When it can be, its presence is considered by almost everybody as proof positive of the tubercular nature of the aural disease. Still further assurance may be obtained by the inoculation of guinea-pigs with the purulent secretion from the ear. The treatment of this typical case would consist, locally, in thorough cleansing and disinfection. Mopping with dry absorbent cotton would be preferable if it were adequate, but it is probable that at least occasional syringing would be necessary. This should be done always with gentleness and extreme care, especially in the presence of sequestra. If odor were present the free use of dioxogen, in full strength, would be advisable. Those who depend upon local medicaments in these cases use chiefly iodoform either insufflated, in powder (alone or mixed with boric acid, one to three); instilled, in glycerated form or in alcoholic. solution (one-half drachm to the ounce); or packed, in strips of iodoform gauze. The general treatment would be directed to the general tubercular condition of the patient. So much for this typical adult case. There are other cases which occur in childhood which, in their way, are equally typical. These are the cases where in the earliest years of life the ears suppurate persistently, with little or no suffering from pain, and where there are adenoid vegetations in the pharyngeal vault, enlarged tonsils, enlarged cervical glands, and the general constitutional dyscrasia which used to be termed scrofulous. Some of these little patients even develop carious disease which involves the mastoid region. In quite a large percentage of these cases it is probable that the aural disease is strictly tuberculous, and in some of them the tubercle bacillus may be demonstrated, not only in the aural secretions but in the tonsils and in the adenoid growths as well. Still other cases fall into a group by themselves. In these there is no general tubercular infection present, but local tubercular disease is developed within the middle ear. This is usually secondary to a throat or nasal infection which has allowed the transmission of the tubercle bacillus through the Eustachian tube to the middle ear, either in secretions forced through the tube during sneezing, coughing or blowing the nose, or by direct transmission along the mucous membrane which, with unbroken continuity, lines the pharynx, the tube and the tympanic cavity alike. Or the local infection within the ear may, in rare instances, be primary, and due to the entrance of the tubercle bacillus from the exterior through the external auditory canal and thence. through a previously existing perforation in the tympanic membrane, or, more probably, to entrance directly through the Eustachian tube from inspired air which bears the bacilli. In all these localized cases there is danger of systemic infection proceeding from the ear, probably through the lymphatic or blood currents, or of intercranial infection conveyed through the same channels. Cases have been reported in which such infection from the ear has apparently occurred. In tuberculous aural disease of this localized nature permanent cures may be effected, although with probable damage to the hearing, and surgical measures may be resorted to in the treatment with far greater freedom than when pulmonary or visceral involvement is present. On looking over the records of tubercular cases which have come under my personal observation, I find but one which exhibits points of sufficient interest to warrant its presentation in detail. The others, without exception, show the characteristic painless development, the relatively rapid destruction of tissue and the marked degree of deafness which we expect to find. To this somewhat unusual case I will call your attention. A. E., male, about 28 years of age, far gone with pulmonary tuberculosis, was referred to me from Rutland, Mass., for examination of the ears and suggestions as to their local treatment. The left ear was the cause of chief complaint and that largely on account of the deafness, which four or five days previous to his visit to me had become so extreme that he could not even hear upon that side through a speaking tube. This left ear had been discharging for three months. On the train during a long journey he had first noted a "crazy feeling" in the head and then pain of heavy character, accompanied by tenderness over the mastoid, which was distinctly paroxysmal, lasting two or three hours at a time-both pain and tenderness then disappearing wholly. For a month past there had been little change in this condition, but upon examination I could find no tenderness over the mastoid. This recurrence of pain was exceptional, but, from its complete remission, it had apparently little connection with any inflammatory state of the ear. Upon examination of the right ear, about which little or no complaint had been made and in which there had never been pain, I found the drumhead nearly gone, only a stump of the malleus handle remaining, and the exposed inner wall of the tympanic cavity insensitive but bleeding upon the slightest touch of the probe. The mucous surfaces were covered with a layer of moist secretion which was not plentiful enough to run from the ear, while the attic-space seemed filled with thick, tenacious pus. The objective appearance upon the left side was similar to that upon the right, but the secretion was far more active. Evidently the pain in this case was of nervous origin. And now a word in closing as to the frequency with which this disease occurs. Prof. Bezold, of Munich, upon analyzing 17,087 cases of aural disease found 127 to be tubercular, i. e., 0.7 per cent. The majority of these patients were presumably in attendance at the public clinics. In my private practice, here in one of the world's centres for tuberculosis, I find the percentage even smaller than that-although many of these cases, in private practice, do not reach the specialist at all, the hopelessness of the general condition making the aural involvement seem of |