bag, so as to exhaust mucus from the tube; he has had a constant feeling of fulness on that side. The middle ear was also inflated and injected with a warm solution of borate of sodium, glycerine, and water. The treatment was followed by rest, and use of maltine as food. Tincture of aconite to quiet the action of his heart, and the use of hydrobromic acid (Squibb's) three times a day. This treatment has entirely relieved the pulsating tinnitus, improved his hearing, and relieved his distress. January 3d was his last visit, and this was his report. The patient, of the impression that the exhausting of the middle ear was the first means of relief which he received, and the use of rest and relaxation from intense study; the hydrobromic acid also acted well, except now and then it would increase too much the action of his heart, then a few drops of tincture of aconite would relieve this sensation.

CASE IX.-J. F. S., aged 45, a distinguished bishop of the Catholic Church, brought me the following note from Hugo Engel, M.D., Lecturer on Electricity, Jefferson Medical College, etc., desiring me to take the case totally under my charge:—

Nov. 27. History.-General condition of health fair; very much exposed, travelling often night and day. The hearing in his left ear has been impaired since childhood, but no pain or discharge for many years; recently the left ear became so troublesome that he had to apply to his physician for relief. His physician had been improving his general health, which owing to exposure to malaria, had affected his whole system, but since the treatment he was better, and thinks his health now good. The chief distress is a constant snapping noise.

The following is the condition of the parts on examination: meatus normal but dry, but with little secretion of cerumen ; membrana tympani of left side sunken and adherent; Eustachian tube not open by Valsalva nor Politzer, but by the use of the Eustachian catheter and chloroform vapor, but no influence on the noise. No fluid or hardened mucus or pus in middle ear; Politzer's acumeter heard close to the ear; loud ticking watch fifteen feet, normal distance three inches right; voice elevated in tone when right ear is closed. No obstruction of nose; hoarseness at times in church; uvula elongated and dropsical; this elongation was treated by astringents, etc., but not being relieved the elongated point was removed and a powder

of tannin and iodoform employed by the patient with entire relief to the loss of voice, which was no doubt owing to mucous plugs on the larynx falling down on the vocal cords. On rhinoscopic examination no ulceration of the orifice of the tube, which was only covered with adhesive mucus. No organic heart trouble or disease of any vessel.

Diagnosis. Slight adherence of the walls of the Eustachian. tube; irregular action of the tendon of the tensor tympani muscle, with evidences of anæmic thinning of the blood. Inflated the middle ear with hydrobromic ether and directed twenty drops. of the hydrobromic acid (Squibb's) three times a day in sugar and water as a lemonade; employed dialysed iron, from ten to thirty drops; diet, a tumbler of warm milk at night instead of porter or ale, with a tablespoonful of maltine; slight counter-irritation by tincture of iodine at the base of the ear, as there was a slight pain. This treatment was kept up, the patient attending somewhat irregularly, when each time inflation of the tube with the ether, and by Feb. 9 all the distressing symptoms had passed away and he found he was perfectly well. Was directed to continue his medicines in diminished doses, and to keep up the extra nourishment, as his duties were a continual drain upon his nervous system.

CASE X. Tinnitus aurium for five years, constant ringing of bells. -Feb. 6, 1880. Margaret P., aged 10 years, a bright intelligent girl; she is at school, but labors under great difficulty in acquiring her lessons, owing to her deafness. Both ears are affected, but the right is the most affected-duration since childhood. With the exception of cold and intermittent fever there was no known cause. At times she suffers from pain and constant ringing of bells. Has been under the care of a physician, but made no progress. The discharge from right ear is constant and of a yellow color; meatus of right ear very irritable, with polypoid granulations; left is also irritable; membrana tympani of right perforated and thickened; left only thickened and drawn inwards; Eustachian tube of right closed; of left open, but narrowed. Loud-ticking watch heard on contact of right; left, two inches; tuning-fork heard on temple, forehead, and top of the head. Nose swollen and turbinated bone inflamed; has nasal catarrh; tonsils of both sides enlarged and pressing on the orifices of the Eustachian tubes; posterior portion of pharynx

covered with granulations; voice muffled and nasal; very nervous. Father is somewhat deaf; mother is delicate in health.

Diagnosis.-Chronic otitis media, with ulceration and polypi. Treatment.-Cleansing ear; use of sulphate of copper to ulcerations, powdered boracic acid, inflation of middle ear, etc.; improvement gradual, but damp weather caused always an increase of the deafness, owing to the swelling of the uvula and tonsils; these were removed under the anaesthetic influence of hydrobromic ether. She was placed upon maltine and dialysed iron; also a mixture of hydrobromic acid, glycerine, and water, for the noises. She has been under treatment for a month with great improvement of the hearing and the disappearance of the noises.

USE OF HYDROBROMIC ACID AND HYDROBROMIC ETHER IN TINNITUS AURIUM AND VERTIGO.

For about two years I have been testing the use of hydrobromic acid both in cases of diseases of the ear, also in cases in which I considered it useful in certain nervous diseases of a part or of the whole nervous system. The first preparation which I employed was made by the formula of Fothergill, which has been the most generally employed. It is given in his “Handbook of Treatment," Amer. edit. of 1877, p. 569. This formula, according to Dr. Edward S. Squibb,' is loose and inaccurate, yielding a complex solution containing much tartaric acid and potassium, and only containing between eight and nine per cent. of hydrobromic acid, and as the dose is stated to be fɔ̃ss to fɔ̃j, by weight, it is only equivalent to four to eight grains of potassium bromide. During 1878 and part of 1879 I used many ounces of this preparation, obtained from one of the very best drug houses in Philadelphia; but I could only say that I derived benefit from the drug in a very few cases-some twenty-eight cases out of one hundred. After I visited Dr. Woakes, of London, who introduced the drug into use in the treatment of certain forms of tinnitus aurium, I told him of my want of success, and he informed me that he had also a like difficulty with certain forms of the acid sold in London, and when he obtained a strong and pure article his success was very gratifying. my return home I had a consultation with Mr. Charles Bullock, the able chemist, of this city, when we discussed the subject,

Notes on Hydrobromic Acid, pamphlet, p. 11.

On

and he advised my employing that made by the most accurate process, as described by Dr. Squibb in the pamphlet before referred to, which he kindly sent me. The formula and process for making an acid of the proper strength is as follows:

Take of potassium bromide six parts;

·

Sulphuric acid, seven parts by weight, sp. gr. 1.838 at 15.6° C. (60° F.)

Add to the sulphuric acid one part of the water and cool the mixture, then dissolve the potassium bromide in six parts of the water, add the diluted sulphuric acid, and set the mixture aside for twenty-four hours to cool, when a decomposition takes place into hydrobromic acid and the sulphate of potassium. I will not go into all the details; suffice it to state that a troyounce of the acid obtained by this process contains exactly 400 minims (401.48 +), and the fluidounce of 480 minims weigh almost exactly 574 grains (573.8 +); a drachm of it, therefore, would contain 50 minims, and would be the bromine equivalent of 30 grains of potassium bromide. A gramme of the acid is equal to 12.86 minims, and therefore 4 grammes would be 51.44 minims, equal to 30.86 grains of potassium bromide—a very large sedative dose. The doses of the acid I find are much less than that required by the potassium bromide. In most of the cases I commence with ten drops in ten teaspoonfuls of water and one tablespoonful of sugar, which makes a pleasant lemonade and is gratifying to a feverish patient. I increase the dose gradually until I arrive at thirty drops, when, if the headache or vertigo or epileptic convulsions are not relieved, and I find some disturbance of the heart's action, I either diminish the dose or employ in conjunction small doses of tincture of aconite until the heart is relieved. In some cases I combine the potassium bromide with the acid when the urine indicates too much acid in the system, or it produces too much irritation of the urinary passages. In a case of great debility with severe vertigo, I advised the combination of the acid with lithium bromide, which salt contains nearly ninety per cent. of bromine, or more bromine and less base than any neutral salt. It is suggested by Dr. Squibb to saturate the acid with lithium carbonate and adjusting the volume of the solution to the dose required. But experiments bear out the idea that bromine when combined with hydrogen proves more active than when combined with potassium. The

acid as made by Squibb's process, is half the bromine strength of the salt, or thirty-four per cent.

I reported twenty-five successive cases of "tinuitus aurium” at the meeting of the Section of Otology of the British Medical Association at Cork. Since that time I have added the above cases, and one successful case of treatment of tinnitus aurium was reported to me by Dr. C. K. Mills, of this city, under the use of hydrobromic acid, and one in which it at first benefited and then the case relapsed. In a case of tinnitus aurium in which there was the distressing symptom of vertigo, large doses of the hydrobromic acid were employed without benefit; but the post-mortem revealed a tumor involving the auditory nerve. I feel sure that the action of the potash salts has a tendency to break down tissue, and to cause the impairment of function of the muscles of the lower extremities ascribed to the bromide of potassium. The physiological action of free bromine is a corrosive irritant to the stomach, producing pain, vomiting, diarrhoea, and death by exhaustion; on dissection the mucous membrane of the stomach and bowels is found softened; while the action of poisoning by a solution of potassa are acrid and caustic taste in the mouth, burning in the throat, nausea, vomiting of alkaline, bloody matters, diarrhea, convulsions, delirium; while in long continued doses it diminishes the coagulability of the blood, with passive hemorrhages, and general weakness and emaciation.

CASE XI.-Feb. 22. B. II., a young lady, aged nineteen, suffering intensely with an attack of scarlet fever with intense cephalalgia, which was not relieved by hot foot baths, active movement of the bowels, cooling lotions, etc, to the head, was directed the hydrobromic acid in ten-drop doses, as before recommended, as a lemonade. After the use of six doses, entire relief to the symptoms, able to open her eyes, and a large, long clot of blood was discharged from the nostrils.

CASE XII.-J. W., aged eighteen, subject to vertigo, tinnitus aurium, and middle ear catarrh, with pain in the head, at times so severe as to disturb her mind and memory. Employed in her case the various means to relieve her middle ear catarrh, and administered thirty-grain doses of potassium bromide, with no improvement in the vertigo or tinnitus aurium for two months; also during another month chloroform, nitrite of amyl, ordinary