For several years I have felt the need of something more powerful and active in relieving the severe pain and inflammation which we so often find in acute drum troubles. Many of us have doubtless been disappointed in preparations containing chloroform, atropine, morphine, etc., when prescribed even for common earache when there is no irritation in the drum cavity. The above preparations have been more satisfactory since the introduction of cocaine. Notwithstanding all that, I have often been compelled to give my patients an opiate to restore needful rest.

Some months ago I ordered from Parke, Davis & Co. the above solution to be used in nasal operations. In a few days a patient, aged 18, came to my office suffering very much with acute purulent otitis media, stating that the pain was so great he had been unable to sleep the entire night. Upon inspection I found the drum membrane very much inflamed, with a bloody muco-purulent secretion exuding from it. He had considerable cold. I syringed the ear with a hot boric-acid solution, and then dropped ten drops of suprarenal liquid with chloretone in it, at the same time requesting the patient to hold his head so as to retain it for ten minutes. His pain ceased before he left the office, which was about thirty minutes. I directed him to continue the same treatment every two or three hours during the day, but not to syringe it. He returned the next morning, stating that he had been entirely free from pain. This treatment was continued about ten days, at which time the pus ceased, the patient being about well.

Shortly after this a man, aged 45, came to my office, stating that he had a rising in his ear and continued pain, without sleep, for several nights. I found a large abscess had burst into the external meatus of the right ear a short distance from the drum, with a free discharge of pus. This generally gives relief. Owing to the location of the abscess, this part being more difficult for medicine to penetrate than the membrana tympana, I added three grains of cocaine to two drams of suprarenal liquid with chloretone. I saturated a piece of cotton and placed it over the part. He continued the same treatment every three hours. He stated the next morning that he had been free from pain since the first application.

During February and March, 1901, three of my children had la grippe, followed by ear troubles. One, 8 years old, had violent pain in the right ear. In less than two hours after the pain commenced

I found inflamed membrana tympana. I did not use hot water, but ten drops of the above preparation, without cocaine, the head being held over for five minutes. The pain ceased after the first application. The same treatment relieved the other two children.

Some weeks after this my little daughter, aged 6, had a relapse about one o'clock at night. The suprarenal not being convenient, I used dry heat. The drum ruptured in less than one hour. The next afternoon she began to have great pain in the other ear. Upon inspection I found the membrana tympana swollen and inflamed; temperature, 102, which remained so for two days. I dropped eight drops of the suprarenal liquid into the ear, with cocaine added. The second application relieved the pain, after which the inflammation soon disappeared. The pus ceased in the other ear in a week by using the liquid three or four times a day without cocaine. Of course I syringed the ear each morning with a boricacid solution.

On March 23 I was called over the telephone at 9 P.M. by a young lady, who stated that she had been suffering all day with pain in one ear, and she felt the pain more severe as the night advanced. Knowing her past experience with her ear, I felt sure that she would have purulent otitis media unless the pain could be stopped at once. I prescribed for her similar to those above, and requested her to report the next morning. She failed to do so. On the morning of the second day I telephoned her. She said the first ten drops gave her relief, and she had a good night's rest.

The following cases, it seems to me, will show the decided effect suprarenal liquid with chloretone and cocaine has upon an inflamed membrana tympana:

C. Y., aged 20, came to my office on April 10, 1901, with this history: His left ear began to pain him the day before as a result of la grippe. The pain became so intense at midnight that he sought the nearest druggist and got what I supposed to be a solution of morphine and atropine (as it was labeled "Poison "), to be dropped in every two or three hours. He was taking antikamnia and codeine tablets every four hours. These failed to procure rest. On examination the inflammation was so great that I expected the drum to perforate. I had him to lie on the sofa for an hour, and kept the ear filled with the suprarenal solution. The pain was relieved before he left the office, and was never felt again. I had him to continue the same until all inflammation disappeared.

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Since May, 1901, I have had many cases similar to the above. Only a few days ago a boy, aged about 13, came into my office with a severe pain in one ear, which had lasted for several hours. He had had several different applications, but without relief. Upon inspection the drum was congested. I added three grains of cocaine to two drams of suprarenal liquid, and had him to use ten drops every two hours. He telephoned me the next morning that he was relieved soon after using the medicine.

Just recently a little girl, aged 11, was sent to me from a neighbering town, with a statement from her family physician that he could not relieve the intense pain she had had for seventy-two hours. Sleep had almost become a thing of the past. She had not been well for some time on account of la grippe, which had left her considerably debilitated. She was pale and exhausted by pain and loss of sleep. She had no fever; appetite, poor; and bowels, constipated. The pain radiated from the mastoid to the vertex. The mastoid was slightly swollen and tender on pressure. There was

a large perforation at the upper and posterior part of the membrana tympani; drum, swollen and inflamed. I syringed with a hot boric-acid solution, then filled the ear with the liquid, cocaine added. She began to get easy in a few minutes. I also gave her by stomach one-sixteenth of morphia, as I feared the pain would return. She slept the entire night. This treatment was continued for several days, during which time she seemed to be quiet until after using the syringe. I left off the syringe and used the liquid, also dry heat in front of the ear. The tenderness and pain over the mastoid soon began to disappear, and her improvement was so fast that I let her go home, with instructions to use the liquid, but not to syringe. The discharge ceased in one week.

Paracentesis should have been done early in this case. Charles H. Burnett has well said that if pain continues over six hours in a child or twelve hours in an adult, without spontaneous rupture of the membrana tympana, paracentesis of the drum membrane should be done. He also states in his valuable book that he has never had acute mastoiditis consecutive to acute otitis media in which he had treated the primary otitis media from the outset.

Usually secondary infection is generally due to the treatment applied by the patient, sometimes by the physician, especially if he uses hydrogen dioxide or excessive syringing, or both. Dropping

irritative medicines into the ear or using nasal douches or irritative medicines in sprays usually ends in purulent otitis media. Never blister over the mastoid in catarrhal otitis media. There is no treatment of more importance than the primary treatment of ear troubles. Asepsis and antisepsis should be strictly carried out in all acute drum troubles.

Suprarenal liquid is also excellent in nasal operations. Dr. Newcomb, of New York, says it is simply beautiful to watch its effects upon the redundant tissue of the nose-how it will shrivel and become pallid when applied. I have applied it to the septum and removed portions from it without hemorrhage. I have used it both locally and internally with some degree of satisfaction in hay fever. Dr. S. Solis Cohen, of Philadelphia, a sufferer of August hay fever, states that he had much relief after taking a tabloid consisting of five grains of suprarenal substance. If coryza, or sneezing, had commenced, it would cease in fifteen minutes, and remain so for a number of hours.

The object of this paper is only to report a few of the many cases which I had last winter, also this winter, and treated more successfully than I have ever done. As you doubtless know, nearly all these cases affected with acute otitis media are left with some deafness, which can be relieved with the Politzer air bag.

In presenting the above for consideration I have failed to tell. you why I believe these three ingredients, when combined, make a most admirable preparation for any irritation or inflammation in the drum cavity. You will observe that most of my cases resulted in an acute catarrhal otitis media, and not purulent, as we generally have them.

I do not recall a single case that resulted in a purulent otitis media if seen in time and could use this suprarenal liquid with chloretone.

In the structure of the middle car the upper part contains a large amount of connective tissue. Infection in this region is followed by an inflammation of the cellular type, while infection of the lower portion of the cavity will result in simple catarrhal inflammation of the lining mucous membrane. The astringent action of this gland acts upon the connective tissue and lessens the congestion. The chloretone is equivalent in anesthetic action to a 2-per-cent solution of cocaine, thereby holding in check the acute pain we generally have in all acute ear troubles.

I do not know of any remedy generally used in the above ear troubles that is so quick and powerful in its physiological action as this suprarenal gland. We are indeed fortunate if our case terminates in acute catarrhal otitis media instead of purulent. In the former our prognosis is generally favorable, while the latter may extend on and on, even under the best treatment, to great pain and death. Many of you practice in the country and small towns, and it is your duty to relieve as quickly as possible these ear cases and never allow a drum to perforate until you have done your full duty. I sincerely hope there is not a man in this Society that will ever look lightly upon an inflamed drum or say that it is not safe to stop an ear from discharging pus. I always feel that a victory has been won when I cure a patient affected with ear trouble.

DISCUSSION ON THE PAPER OF DR. HERRON.

DR. G. H. PRICE, NASHVILLE: I have been much interested in the report of these cases by Dr. Herron, because if there is any one class of cases which gives us concern from the beginning, it is that class so graphically described by the essayist. The profession, as a whole, is prone to regard earache as a slight affection and to look upon it with little concern; but, so far as I am personally concerned, I never see a patient with an acute catarrhal inflammation of the ear, in which pain is a prominent symptom, that I am not concerned and frequently alarmed. It is a condition often met with, and I have had fair success in treating it, though not always following out the lines laid down. I have had some experience with the suprarenal extract made from the desiccated gland in the office, or the adrenaline chloride. In prescribing this for the use of the patient, I prescribe the adrenaline without the chloretone. The action of this solution upon a congested mucous membrane, or partly mucous, is to contract at once the capillary blood vessels, and thus force out the blood circulating in those parts. I have succeeded in doing this in the early stages and abating the pain in a short time. I have not used this remedy, however, as extensively as Dr. Herron, but I have seen cases suffering with an acute attack of earache and perforation where an early application of local remedies might have prevented the perforation. Where rupture has not taken place some advise the use of the paracentesis needle for the purpose of opening the drum cavity and allowing the pus to escape. I rarely resort to that measure. Under ordinary conditions I have found that the application of hot water from a fountain syringe, immediately followed by instillation of chloroform, one part to eight parts of olive oil, will reduce the pain and induce quiet on the part of the patient. However, I am glad to hear the Doctor's suggestions, and at the first opportunity