Iodine Phosphorus G A R D N ; IODINE AND PHOSPHORUS BY R. w. GARDNER, Pharm. C. NEW YORK PART I IODINE FOR INTERNAL USE Page; 9 PART II PHOSPHORUS AND THE-HyPQPHOSPHlTES PAGri 156 Wiuja j Street New aWk 1902 COPYRIGHT I902 BY R. W. GARDNER Physicians Who Have Contributed Clinical Matter Upon Gardner's Preparations. J. M. Abbott, M. D., Trilby, Fla. Chas. W. Aitkin, M. D., Flemingsburg, Ky. J. D. Albright, M. D., Philadelphia, Pa. ----- Phthisis W. E. Anthony, M. D., Providence, R. I. - - - - - Phthisis F. Archer, M. D., Dublin, Texas. P. Barnum, M. D., Jacksboro, Tenn. ----- Malaria J. Bailey, M. D., Dawson, Ky. ----- Phthisis, Asthma . R. Barton, M. D., St. Louis, Mo. C. E. Baum, M. D., Providence, R. I. - - - - - - La Grippe Dr. Bauman, New Haven Hospital, New Haven, Conn. Inflammatory Rheumatism R. K. Barnes, M. D., Brooklyn, N. Y. - - - - Enlarged Tonsils W. Banta, M. D., Calistoga, Calif. C. E Belcher, M. D., Clearfield, Pa - - - - Catarrh of Bladder F. A. Benham, M. D , Oak Park Sanitarium, Elkhart, Ind. E. L. H. Berry, M. D , Jerseyville, Ills. W. H. Bentley, M. D., LL.D., Cold Spring, Woodstock P. O., Ky. Smallpox, Acute Pneumonia, Phthisis Nathan T. Beers, Jr., M. D., Brooklyn, N. Y. H. D. Bishop, M. D., Cleveland, Ohio. ------ Rachitis S. A. Binion, M. D., New York City, N.Y. - - - - Syphilis A. T. Birdsall, M. D., Brooklyn, N. Y. - - - - - - Malaria T. Blank, M. D., St. Louis, Mo. ------- Phthisis W. D. Blatchley, M. D., Fort Scott, Kansas. J. M. Blakesby, M. D., Germantown, Pa. Homer Bowers, M. D., New Ross, Ind. - - - Pneumonia, La Grippe A. H. Boler, M. D., Chicago, Ills. - - _ Exophthalmic Goitre R. S. Bolles, M. D., Lucas, Ohio - - - Hepatic Abscess, Pneumonia M. F. Bozinch, M. D., Chicago, Ills. M. Borter, M. D., Cleveland, Ohio. F. H. Brand, M. D., Moline, Ills. - Nervous Syphilis, Catarrh K. A. Briggs, M. D., Berlin Mills, N. II. Q. A. Bridges, M. D., Guilford, Me. ----- La Grippe Edward F. Brennan, M. D., New York City. 4 S. J. Brownson, M. D., Elkins, Arkansas ----- Cough Isaiah Brothers, M. D., Youngstown, Ohio - - - Intermittent Fever George P. Burtchby, M. D., Oskaloosa, Iowa. F. A. Burrall, M. D., New York City - - Atnyloid Liver, Obesity W. W. Burns, M. D., Polo, Ills. F. E Burgevin, M. D., Spiro, I. T. • ... Malarial Fevei C. O. Buck, M. D., Lexington, Miss. - Pernicious Intermittent Fevei J. C. Campbell, M. D., Denmark, N. C. La Grippe J. J. Caldwell, M. D., F. S. S. London, Baltimore, Md. Asthma, Pertussis J. B. Carver, M. D., Fort Scott, Kansas - - - Exophthalmic Goitre J. K. Cantrell, M. D., Alton, Mo. - - Sclerosis of Liver, Pupura A R. Carman, M. D., New York City. J. P. Caldwell, M. D., St. Paul, Minn. Henry Chandlee, M. D., Baltimore, Md. - - Locomotor Ataxia J. V. Cleaver, M. D., Akron, Ohio - - - Syphilis, Rheumatism James E. Clawson, M. D., Philadelphia, Pa. - Enlarged Cervical Glands G. R. Connally, M. D., Shannon, Miss. Almon H. Cooke, M. D., Buffalo, N. Y. - Asthma, Chronic Rheumatism John Cooper, M. D., Brooklyn, N. Y. - - - - - - Gout Milton P. Creel, M D., Central City, Ky. - - - Exophthalmic Goitre James, Craig, M. D., The Late, Jersey City, N. J. - Inflammatory Rheumatism Alfred R. Crain, M. D , New York City - Chronic Asthma J. W. Daniel, M. D., Houston, Texas. - Syphilis, Asthma F. E. Daniel, M. D., Austin, Texas. ------ Eczema Walter M. Darnell, M. D., Belton, Texas. ----- Phthisis Leon De Bremon, M. D., The Late, Knight Leg. Honor, Mem. Ord. Imp, Ot. Medj., Mem. N. Y. County Med. Soc., Neurol. Soc., Med. Legal Soc., late Clinical Assistant to Dr. Churchill ----- Phthisis D. C. De Wolfe, M. D., Bridgeport, Conn. F. F. Dickman, M. D., Fort Scott, Kansas. A. Dietrich, M. D , Frontenac, Kansas. C. L. Dodge, M. D. (Kingston, N. Y. - - - - - La Grippe Samuel P. Duffield, M. D., Ph. D., Dearborn, Mich. - - Phthisis Edgar Du Cane, B. A., M. B., 5 Park Lane, Swindon, England. Elmer B. Eddy, M. D., Providence, R. I. Henry B. Esmond, M. D., Ph D., West Fairlee, Vt. A. U. Evarts, M. D., La Porte City, Iowa. ----- Phthisis Richard B. Faulkner, M. D., Pittsburg, Pa. ----- Phthisis C. I. Faunce, M. D., Norwich, Conn. ----- Neurasthenia Henry M. Field, A. M., M. D , LL.D., The Late, Newton, Mass. - Asthma, Catarrh 5 Elbert E. Fisher, M. D., Rodney, Iowa. - Chronic Bronchitis, Syphilis T. C. Fitzsimmons, M. D., Wilkes Barre Pa. W. B. Fletcher, M. D., Indianapolis, Ind. ----- Exophthalmic Goitre, Genito-Urinary Diseases F. R. Fraker, M. D., Marlboro, N. Y. Phthisis Alexander C. Freeman, M. D., Kokomo, Ind. - Catarrh F. R. Garlock, M. D., Racine, Wis. Catarrh, Rheumatism, Bronchitis, [Eczema B. F. Gardner, M. D., Atlanta, Ills. ----- Typhoid Fever E- T. Gazely, M. D., Carlsbad, New Mexico. Abraham Glickstein, M. D., New York City - - - - Bronchitis S. A. Gluck, M. D., Brooklyn, N. Y. - - - Bronchitis, Laryngitis R. J. P. Coodwin, M. D., Malden, Mass. - - - Catarrh, Rheumatism, Neuralgia, Bronchitis Malcolm Graham, M. D., Jonesville, Mich. ----- Phthisis Gordon R. Hall, A. M., M. D., Brooklyn, N. Y. - - - Malaria Mat. Harolson, M. D., Sunset, Mo. ------ Asthma J. Stinson Harrison, M. D., Washington, D. C., 'Croup, Asthma, Bronchitis Allen McLane Hamilton, M. D., New York City - Exophthalmic Goitre Thomas Hay, M. D., Cape May, N. J. - - Bronchial Catarrh, Anaemia P. L- Hilsman, M. D., Albany, Ga. - ----- Ta Grippe H. E. Houston, M. D., C. M., Kalispell, Mont. - - - - Syphilis J. W. Hodge, M. D., Niagara Falls, N. Y. E. E. Holt, M. D., Portland, Me. Amzi W. Hon, M. D., Bloomington, Ind. James Lewis Howe, M. D., Lexington, Va. S. J. Holley. M. D., Brooklyn, N. Y. - - - - - Hepatic Colic C. H. Hughes, M. D., St. Louis, Mo. Judson A. Hulse, M. D., Akron, Ohio. C. F. Huddleson, M. D., Troy, N. Y. William F. Hutchinson, M. D., The Late, Providence, R. I. Nerve Feeding E. P. Hurd, M. D , The Late, Newburyport, Mass - - - Asthma William H. James, M. D., Pennsville, N. J. - - - - - Malaria J. R. Johns, M. D., Philadelphia, Pa. ----- Neurasthenia W. A. Jones, M. D., Minneapolis, Minn. William Judkins, M. D., Cincinnati, Ohio - - _ . Hay Fever F. John Kaufman, M. D.. Syracuse, N. Y. - Strumous Glands, Bronchitis, Potts' Disease J. M. Keller, M. D., Hot Springs, Ark. - - - Exophthalmic Goitre Robert C. Kenner, M. D., Louisville, Ky. - Asthma, Bronchitis, Syphilis P. D. Keiser, M. D., New Mahoning, Pa. - - - Chronic Bronchitis George Kerr, M. D , Pierson, Volusia Co., Fla. George S. Keith, LLD., M. D., Currie, Edinboro, Scotland. 6 John Kershaw, F. R. C. S., L. R. C. P., Didsbury, Manchester, England. ----- Affections of Mucous Membranes Ferdinand King, M. D., New York City - - Genito-Urinary Diseases C. T. King, M. D., Porter's Corners, N. Y. - • - - - Cough Charles H. Knight M. D., New York City. - - - Reflex Asthma M. K. Krieder, M. D. Goshen, Ind. ------ Fibroma George Frederick Laidlaw, M. D., New York City. Genito-Urinary Diseases John S. Lawson, M D , Sans Bois, Ind. Ter. H. J. Laciar, M. D., Bethlehem, Pa. - Diphtheria F. B. Laurich, M. D., Ph. D., New York City, N. Y. Charles Lengel, M. D., Kansas City, Mo. Rheumatism, Asthma, Hay Fever J. H. Lennon, M. D., Little Rock, Ark. Louis Lewis, M. D., F. R. C. S., the late. Philadelphia, Pa. Asthma, Syphilis Abbott B Lichtenwalner, M. D., Philadelphia, Pa. I. N. Love, M. D., New York City. S. T. Lowrie, M. D., Lore City, Ohio. ..... Phthisis John C. Ludwig, M. D., Cincinnati, Ohio. Chas. W. McIntyre, M. D., New Albany, Ind. .... Asthma Thomas H. Manley, M. D., New York City. ... Syphilis, Struma S. C. Martin, M. D., St. Louis, Mo., Prof. Derm, and Hygiene, Barnes Med. College. - - Hay Asthma James S. Marshall, M. D., Blossom, Texas. George H. Millington, M. D., Rockport, Texas. Prostatic Hypertrophy Charles K. Mills, M. D., Philadelphia, Pa., Prof. Mental Dis. and Med. Juris. Univ Penn., Neurologist to Philadelphia Hosp. Arthur E. Mink, M. D , the late, St. Louis, Mo., Cerebro Spinal Syphilis C. F. Mitchell. M. D., C. M., Cleveland, Ohio. • - Syphilis, Goitre C. N. Miller, M. D., San Francisco, Calif. - - - - La Grippe E. L. Morse, M. D., Ashtabula, Ohio. L. J. Morton, M. D., Brooklyn, N. Y. - - - Intracranial Syphilie John W. Murphy, M. D., Sullivan, Ind. - Syphilis, Eczema L. S. Nicholson, M. D., Washington, D. C. - - - - Bronchitis Samuel Robinson Nissley, M. D., Elizabethtown, Pa. - Parotitis, La Grippe, Syphilis J. P. Oliver, M. D., Boston, Mass, - - Asthma S- A. Oren, M. D., Davis, Ills. Goitre A. Kidder Page, M. D., Boston, Mass. D. J. Parsons, M. D., Sweet Springs, Mo. ----- Phthisis Joseph M. Patton, M D., Chicago, Ills., Prof. Intern. Med. Chi- cago Polyclinic. ---------- Phthisis J. A. Petrie, M. D., Phillipsburg, N.J. - - - - - Diabetes W. T. Peyton, M. D., Louisville, Ky. - Bronchitis, Chronic Rheumatism Lewis G. Pedigo, M. D., Leatherwood, Va. Rheumatism, Pleurisy, Scrofula Frederic H. Plummer, M. D., Chelsea, Mass. William Porter, A. M., M. D., St. Louis, Mo., Phys to Prot. Hosp. St. Luke's and City Hospitals - - - - Phthisis Edwin T. Randall, M D., Brooklyn, N. Y. Syphilis, Chronic Rheumatism H. T. Richardt, M. D., East Orange, N. J. G. M. Romig, M. D., Allentown, Pa. - - - . _ Malaria A. Rose, M. D., Lebanon, Ky. - - Genito-Urinary Diseases, Syphilis J. E- Russell, M. D., Brooklyn, N. Y. - - Congestion of the Lungs M. G. Salley, M. D., Orangeburg, S. C. - - - Typhoid Fever H. Schoonmaker, M. D., Seneca Falls, N. Y. - - Malarial Fever C. S. Simpson, M. D., Macon, Ky. John V. Shoemaker, A. M., M. D., Philadelphia, Pa., Prof. Skin and Ven. Dis. Med. Chir. Hosp , Phys, to Phil. Hosp, for Dis. Skin, etc. Syphilis, Asthma, Phthisis, Skin Diseases, Eczema, Hay [Fever V. T. Smith, M. D., Detroit, Mich. - - ... Cough Q. C. Smith, M. D., Austin, Texas ------ Malaria L. B. Snow, M. D., Cleveland, Ohio. ----- Enteritis A. Springer, M D., Lewiston, Me. Logan Stanley, M D , Fincastle, Ind. C. C. Stephenson, M. D., Little Rock, Ark. - - Difficult Dentition H. F. Stowell, M. D., Rochester, N. Y. - Eczema, Syphilis, Fibroma S. Stone, M. D , Louisville, Ky. ------ Meningitis William S. Stoakley, M. D., Cherriton, Va. - - - Rheumatism James Stinson, M D., San Francisco, Calif. - La Grippe Samuel Patterson Stafford, M. D , St. Louis, Mo. Richard H. Taylor, M. D., Hot Springs, Ark. - . - _ Syphilis W. V. Taylor, M. D., Olla, La. J. C. Tanner, M. D., Hartford, Conn. ----- Asthma James J. Terhune, M. D., Brooklyn, N. Y. - - - _ Fibroma William E. Thomas, M. D., Brooklyn, N. Y. - - Cerebral Gumma W. S. Todd, M. D., The Late, Ridgefield, Conn. T. Henry Tubman, M. D., Cleveland, Ohio. - Diarrhoea L. A. Turnbull, M. D., St. Louis, Mo., Visiting Phy. to Fem. Hosp. [Nephritis, Syphilis W. T. H. Von Beverhaudt, L R. C. P., Elvington, Yorks, Eng- land. ----------- - Asthma G. M. Walker, M. D., Soddy. Tenn. P. G. Waller, M. D., New Baltimore, N. Y. C. H. Wallace, M. D., St. Joseph, Mo. . - - Exophthalmic Goitre A. J. Wakefield, M. D., Jacksonville, Fla. - Facial Neuralgia William H. Wehner. M D., Germantown, Philadelphia. Pa. W. J. Weiselbaum, M. D., Savannah, Ga. 7 8 H. T. Wharff, M. D., Edwardsville, Ills. William H. White, M. D., Bloomfield, N. J. - - Malarial Fever J. W. Williams, M. D., Weston, Ohio. Conrad Wienges, M. D., Jersey City, N. J. - Inflammatory Rheumatism W. C. Wile, A. M., M. D., LED., Danbury, Conn. Eczema, Syphilis, Asthma, Genito-Urinary Diseases, Bronchitis Thos. Wildes, M. D., New York City. ----- Bronchitis James A. Williams, M. D., New York City - - - Fibroma, Bronchitis John W. Williamson, M. D. Boydton, Va. John C. Willson, M. D., Flint, Mich. ... - Phthisis, Asthma J. C. Wilson, M. D., Edinboro, Pa. - - - - Chronic Catarrh Franklin C. Woodruff, M. D., Newark, N. J. - - - - Gastralgia J. T. Wrightson, M. D., Newark, N. J. Phthisis W. Gill Wylie, M. D., New York City. ----- Bronchitis I. Burney Yeo, M. D., F. R. C. P., London, England, Prof. Clin. Therap. King's Col. Hosp, and Auth. " Man. Med Treat, or Clin. Therep." A. H. Young, M. D., Ripley, Tenn. S. T. Yount, M. D., Chicago, Ills. - Bronchitis, Chronic Rheumatism T. J. Yount, M. D., Lafayette, Ind. - • - Chronic Rheumatism PART I IODINE FOR INTERNAL USE Its various salts and combinations Therapeutically and Chemically considered GARDNER'S SYRUP OF HYDRIODIC ACID Its superiority to all other forms of Iodine Therapeutical Indications with Clinical Data INTRODUCTION. It is presumed that every physician desires to prescribe only such remedies as will produce the best results with the least in- convenience to his patient. His personal interests, the welfare of his patients, his repu- tation as a successful practitioner, his sense of duty in fulfilling to the best of his ability the weighty responsibility of his calling, all lead him to adopt this course. Being assured that the above reasoning will appeal to all members of the profession alike, and that its truth will be acknowledged, it follows that the selection of the medicinal agents relied upon for treatment of disease is one of the most important considerations which can occupy the careful attention of the prescriber. The writer has been engaged for many years in the study of two important elements, Iodine and Phosphorus. Unlike other manufacturing houses, his laboratory has been devoted exclusively to the perfection of the most available forms of these two elements for medical purposes. He has never attempted to manufacture an extended list of miscellaneous preparations, but has devoted his entire time, not The writer wishes to gratefully acknowledge his indebtedness to the many eminent members of the medical profession who have contributed unsolicited testimony upon his Special Preparations, either in the Medical Journals, or in personal letters to him. The language of some of these gentlemen has been freely quoted in the following pages. As nearly all the literature pertaining to the therapeutics of Hydriodic Acid has been drawn from the experience of these gentlemen and others who have used Gardner's Syrup, the whole medical profession, as well as the writer, are under obligations for their clinical contributions. • R. W. Gardner. 156 William Street, New York. Introduction. 12 only to the pharmaceutical production, but also to the therapeu- tical and physiological application of compounds of these two elements. The education of the ordinary pharmacist, or manufacturer, does not fit him for original investigation and application of remedies to diseased conditions, as therapeutics forms no part of his education. His aim is to produce a preparation pleasing to the eye and, if possible, permanent. He has made no study of the physiological action of remedies upon the organism ; what deleterious effects certain impurities in the preparation may ex- ert upon a debilitated and wasted patient ; having no knowledge of pathology, he cannot follow the action of a remedy from cause to effect. The physician, on the other hand, is looking for the imme- diate results of treatment upon his patient-is watching for symptoms of improvement-the effect, in other words, of the medicine he has prescribed. Elegance in appearance is, with him, secondary to the therapeutic results achieved. The writer has always considered therapeutic activity of the first importance ; his preparations differ from all others in many particulars essential to the best therapeutical results. Conse- quently, the same satisfactory action is not obtained from similar preparations made by pharmacists or manufacturing houses. While therapeutic action has invariably been the main con- sideration in the preparations of the writer, pharmaceutical elegance has also been elaborately studied. In the combination of these two leading features and the careful attention which has been paid to them, will be found the reasons advanced for their superior value as medicinal agents. That these claims are true, and that the special preparations of the writer are superior, not only in therapeutic activity, but also in pharmaceutical elegance, is attested by thousands of medical practitioners who have constantly prescribed them for over twenty-five years. It is on this account, and for the reasons above stated, that the writer appeals to the profession, either to designate Gardner's Alkaline Iodides. preparations by name, when prescribing, and to instruct pharma- cists that no substitute will be accepted in place of them, or else, in simple justice to him, not to hold him responsible for any con- sequences which may ensue from the dispensing of crude.1 and im- pure substitutes, as Gardner's. Iodine-in chemical combination with various bases, has long been recognized as the most valuable alterative and resolvent of the materia medica. In common with many of the other ele- ments, iodine in its pure state is not suited to internal medica- tion, in consequence of its irritating and caustic action on the mucous membranes. It appears to be a natural law, that Ele- ments, as such, are rarely directly appropriated by living organ- isms. Nature almost invariably selects such elements as are re- quired, from their various chemical combinations and modifica- tions. It was found necessary, therefore, to administer iodine combined with a base, to effect its assimilation and modify its irritant action. The forms almost universally employed were the iodides of potassium and sodium which are cheaply and easily prepared. Notwithstanding that these iodides are each combinations of two irritant substances and are borne with great difficulty by the organism, they were almost entirely depended upon for the internal administration of iodine until 1878. 13 CHEMICAL AND THERAPEUTICAL VALUE OF THE IODIDES. Iodide of Potassium.-100 parts of this salt represent 76.43 of Iodine and 23.57 Potassium. The irritant action of iodide of potassium is well known. This objectionable feature is so marked that frequently the remedy must be suspended. Phy- sicians have long recognized the necessity of exhibiting iodide of potassium only after meals, to avoid as much as possible its irri- tant action upon the fauces and the mucous surfaces of the stom- ach. When administered after meals, its admixture with the food renders it less liable to come in direct contact with the mu- Alkaline Iodides. cous surfaces. But while the irritation is thereby slightly less- ened, the physiological action of the remedy is also much impaired by its chemical union with the various food products. In acid conditions of the stomach secretions, more or less iodine is liber- ated when this salt is administered. Iodide of potassium, having an alkaline reaction, neutralizes the hydrochloric acid in the gastric secretions, causing indiges- tion, loss of appetite and depression. These symptoms are so universally produced by this remedy that they are recognized and acknowledged by the profession everywhere. Iodide of Sodium.-100 parts of this salt represent 84.61 of Iodine and 15.39 of Sodium. This salt contains slightly less of the base than the iodide of potassium and is thought by many to be less irritant, but the difference is not marked. In other respects it is similar to iodide of potassium. It is necessary to administer both of these iodides in the maximum dose tolerated by the patient to produce the desired therapeutic effect. Their field of application is also limited, as in many conditions requiring the alterative or sorbefacient action of iodine, the remedy cannot be tolerated. Iodide of Cadcium.-100 parts of this salt represent 86.40 of Iodine and 13.60 of Calcium. Its properties are simi- lar to the other alkaline iodides ; it possesses no advantages over them and is seldom prescribed. Iodide of Iron.-100 parts of Ferrous Iodide represent 81.92 of Iodine and 18.08 of Iron. The dose of Iodide of Iron is so small that the amount of Iodine contained therein is of lit- tle advantage. It is more relied upon for its chalybeate action than for its alterative effect. It can never be depended upon for the constitutional action of iodine. Iodide of Mercury (Mercurous).-100 parts represent 38.88 of Iodine and 61.22 of Mercury. The small dose of this salt renders the iodine constituent of very little therapeutic value. Iodide of Mercury (Mercuric).-100 parts represent 55.89 of Iodine and 44.11 of Mercury. The dose of the mer- 14 15 Iodine Strength. curie iodide being much less than that of the mercurous iodide, the remarks applied to the latter have still greater force in the use of the mercuric iodide. These two last named salts are ex- tremely useful as a means of exhibiting mercury, but so far as the effects of iodine are concerned are of little avail. Iodide of Strontium.-100 parts represent 56.47 of Io- dine and 19.48 of Strontium, combined with 6 molecules of water 24.05. The use of this salt has been advocated on account of the large proportion of iodine contained in it. The proportion, how- ever, is not so large as in iodide of potassium. This is probably a somewhat better form, but it by no means meets the requirements of an active and non-irritant form of iodine. The relative proportions of Iodine and Base in the following compounds are graphically shown by the lines under each element. HYDROGEN IODIDE (Hydriodic Acid). Hydrogen Iodine SODIUM IODIDE. Sodium Iodine Potassium POTASSIUM IODIDE. Iodine It will be seen from the above table that the proportion of Iodine in Hydriodic Acid is as 127 to 1. In Iodide of Sodium the proportion of Iodine is as 6 to 1. In Iodide of Potassium the proportion of Iodine is as 19 to 6. Iodide of Hydrogen (Hydriodic Acid). Hydriodic Acid (Iodide of Hydrogen) was suggested by Buchanan in 1837 as a substitute for the alkaline iodides, upon the supposition that all other forms of iodine were changed into Hydriodic Acid before absorption. He suggested the prepara- tion of an aqueous solution of it by double decomposition be- tween iodide of potassium and tartaric acid in equivalent pro- portions ; this process resulted in a solution of hydriodic acid and bi-tartrate of potassium, a bi-product, which could not be entirely removed. The instability of this preparation, due to the feeble affinity existing between its elements, presented an in- superable objection to its use. Hydriodic Acid is a chemical combination of hydrogen and iodine (HI), in which these elements are held together by a very feeble affinity, the tendency being for the hydrogen to combine with atmospheric oxygen, setting free an equivalent of iodine. The atomic weight of Hydrogen being 1, and that of Iodine 127, this combination contains of one part Hydrogen and 99/^ parts of Iodine by weight. It is a heavy, colorless gas, very soluble in water, and im- mediately decomposed by oxidizing agents. In 1855, Murdoch suggested that hydriodic acid be prepared as a syrup, as sugar had been found to slightly retard its decom- position. A preparation, founded upon Buchanan's formula, was made official in the United States Pharmacopoeia of i860, as " Solu- tion of Hydriodic Acid " ; it was prepared by double decompo- sition, contained secondary bi-products, decomposed almost HISTORY. 17 History of HI. immediately after its preparation, and could never be obtained in a fit condition for administration, as it always consisted of vary- ing proportions of free iodine in a solution of hydriodic acid. The free iodine rendered the preparation too irritant to be borne, and patients were unable to tolerate it. It was, therefore, expunged from the United States Phar- macopoeia of 1870, as a practically worthless preparation and no substitute was suggested. In 1872, Dr. Wylie, of Chester, S. C., employed a solution of hydriodic acid, prepared similarly to Buchanan's formula, but at once combined with syrup, by which means the decomposi- tion was sufficiently retarded to practically test its therapeutic value. His son, Dr. W. Gill Wylie, the present eminent specialist of New York City, employed the same preparation in cases of asthma and some other conditions with success, and suggested to the writer that he undertake an investigation of the subject, with a view of preparing a stable preparation which could be re- lied upon for medicinal use. After much study and investigation the writer placed upon the market, in 1878, the first stable preparation of Hydriodic Acid ever made, under the name of " Gardner's Syrup of Hydri- odic Acid." He discarded all the old methods of manufacture and prepared it directly from pure, resublimed Iodine, when it was at once mixed with syrup. His manipulative methods were so perfected that decomposition was prevented for several years, and then occurred only when the preparation had been exposed to a high temperature, or to the air, for a long period. As soon as it was introduced the theory of its action was fully substanti- ated by clinical experience ; it not only proved to be superior in therapeutic results to iodide of potassium and the other forms of Iodine which had been in use, but was absolutely free from the objections to them, producing none of their bad effects. It was also found to meet a number of conditions in which iodide of potassium exercised no remedial action, thus extending the use of Iodine into new channels, previously unknown. Therapeutics of HI. 18 Dr. W. Gill Wylie, of New York, was the first to test it, and published a paper upon its use in " The New York Medical Record," May 10th, 1879. The official formula adopted at the 1880 revision of the U. S. Pharmacopoeia, having been found unsatisfactory after ten years of trial, was discarded, and at the 1890 revision was replaced by the present official formula. This is a return to the crude method in use thirty years ago, and was adopted to avoid a troublesome and malodorous laboratory process and substitute an extemporaneous one, more suited to the facilities of an ordi- nary Pharmacy. It meets the convenience of the Apothecary more than it does the requirements of the patient and physician. Either this preparation, or some of the countless imitations of Gardner's Syrup, supplied by manufacturing houses in bulk to supply the demand of substitutors for ''Just as good" pre- parations, is almost invariably dispensed when " Gardner's" Syrup is not specifically designated on the prescription, and in many cases even when the latter is specified, if the physician is lukewarm and does not firmly forbid such practices. The experience of the profession in the use of this prepara- tion has shown such marvelous results since its first introduc- tion that Hydriodic Acid has become famous. This experience opened a new field in the application of iodine to diseased conditions, as this new remedy possessed none of the objectionable features which had characterized all other forms of iodine, and rendered it possible, for the first time, to administer iodine at the most favorable period for immediate ab- sorption, unaltered by food products, viz.: half an hour before meals. The alkaline iodides are so irritant that they must al- ways be administered after meals, so that by mixing with the food their irritant action is modified. This modification is in- variably at the expense of the activity and efficiency of the remedy. Gardner's Syrup of Hydriodic Acid has none of these dis- THERAPEUTICS. 19 Therapeutics. advantages; being absolutely non-irritant, and of slightly acid reaction, it can be administered when the stomach is empty and is rapidly absorbed unchanged. Hydriodic Acid is not decom- posed by Hydrochloric Acid, even when the latter is added to it in concentrated form. Hydriodic Acid contains the largest proportion of Iodine of any chemical combination of this element. Hydrogen Iodide (Hydriodic Acid). H '78 I - HI I 99.22 j - Potassium Iodide. • K 23.57 ) _ jq I 76.43) Sodium Iodide. Na 15.39) -Nai I 84.61 J These figures show the proportion of the elements in 100 parts. (Gardner's Syrup contains 1.28 per cent. HI-) Not only does Hydriodic Acid contain a much larger pro- portion of Iodine than the alkaline iodides, but it has been proven by clinical experience to be far more active therapeutically, and efficient in a much smaller dose. In Hydriodic Acid the iodine is in combination with hydro- gen, one of the elements of the natural secretions of the body, and is therefore in physiological harmony ; having an acid reaction, it does not neutralize the gastric juice, and thus cause indigestion, loss of appetite and consequent depression. All of these symptoms are well known to be the result fol- lowing the use of the alkaline iodides. Gardner's Syrup of Hydriodic Acid does not produce any of these effects, even after prolonged administration, and the full physiological action of iodine is obtained without the slightest inconvenience to the patient. Not the least of its advantages is the fact that it has an agree- able, sub-acid taste, resembling lemon syrup, hence, patients can take it for long periods without repugnance. This preparation has been employed in a large number of cases of profound syphilitic lesions of the brain and nervous sys- tem ; cases in which no form of iodine had heretofore been em- Respiratory Diseases. ployed, except the potassium and sodium iodides, and it has been found necessary to administer these, in such cases, in heroic doses, to accomplish the desired alterative action of the iodine. With Gardner's Syrup of Hydriodic Acid, however, the same desirable results have been attained with only ordinary doses, continuously administered. Notwithstanding that in these cases it was necessary, owing to the chronic nature of the disease, to exhibit this remedy for prolonged periods, no unpleasant symptoms whatever were ex- perienced by the patients. Hydriodic Acid possesses all the antiseptic properties of io- dine-all its alterative action. Its use as an internal antiseptic is one of its most remarkable applications. Being absorbed so promptly that it can be detected in the urine in ten minutes after administration upon an empty stomach, having in this short time passed through the circulation, it will be seen that as an internal antiseptic it must be invaluable. Iodine in other forms is not available for internal antiseptic action owing to the irritation produced, hence Hydriodic Acid affords the first effective means that has ever been available for this purpose. Consequently its use in a great variety of septic conditions will be apparent. In forming an estimate of the therapeutic value of Hydriodic Acid, it should be borne in mind that it differs materially from the iodides of potassium and sodium in its chemical composition ; inferences drawn from the observed effects of these salts, and their relative iodine strength, must therefore be modified when the difference in chemical composition and greater therapeutic activity of Hydriodic Acid is considered. 20 Diseases of the Respiratory Tract. It is acknowledged that there is scarcely any other remedy in the chronic form of these diseases which possesses such cura- tive powers as Hydriodic Acid. The air passages are relieved from the obstructing morbid secretions, breathing is soon re- stored to the normal, the thick, viscid mucus is detached from 21 Asthma. the mucous surfaces by the underflow of normal secretion, the membrane itself is stimulated to a more healthy activity, the fre- quent, foul-smelling, septic condition is corrected by the anti- septic action of the contained iodine, and the whole series of morbid symptoms are removed, if the remedy is used sufficiently long and with discrimination. ASTHMA. J. P. Oliver, M. D., the celebrated throat specialist, of Bos- ton, writes: " Begin with small doses, twenty or thirty drops well diluted with water, and taken about half an hour or an hour before meals. Increase the dose gradually, and a tablespoonful dose should not be exceeded. The Syrup of Hydriodic Acid pre- pared by R. W. Gardner, of New York, I consider the best." 1 J. V. Shoemaker, A. M., M. D., writes: " Gardner's Syrup of Hydriodic Acid renders excellent service in asthma, chronic induration of the lungs after pneumonia, pleuritic exudations, and in some skin diseases." 8 Chas. Lengel, M. D., Kansas City, Mo., says : " I have prescribed your Syrup of Hydriodic Acid in many cases of rheumatism, asthma, hay fever, bronchitis, and laryn- gitis, with excellent results. It has given me more satisfaction in these cases than any remedy I have used during my thirty years' of practice. ' ' J. C. Willson, M. D., Flint, Mich., says : " I have used Gardner's Syrup of Hydriodic Acid and have been agreeably surprised at its success in treatment of asthmatic cases." In a paper on ''The Treatment of Asthma," Chas. W. McIntyre, M. D., New Albany, Ind., says: " Gardner's Syrup of Hydriodic Acid is a remedy which is fitting in the interval in all cases of asthma. It tends to lessen the susceptibility of the tubes to attacks of dyspneea and brings about a cessation of the attacks. i Boston Med. and Surg. Journal, Meh. 4th, 1880. 2 Materia Medica, Pharmacology and Therapeutics, Shoemaker, Vol. 2, p. 706, 1891. Asthma. 22 Iodide- of potassium has long enjoyed popularity in the treatment of asthma, but owing to the establishment of iodism it cannot be taken for a period long enough to bring good results in all cases. Gardner's Syrup of Hydriodic Acid does not produce the disagreeable effects of alkaline iodides, but brings about the identical results which we are anxious to obtain with them." W. T. H. Von Beverhoudt, L. R. C. P., Elvington, York, England, March 26th, 1901, reports: " I have tried Gardner's Syrup of Hydriodic Acid in a case of severe Asthma, and with very good results. I think it a very good preparation." A. R. Carman, M. D., New York City, April 15th, 1901, reports: " I have used Gardner's Syrup of Hydriodic Acid in large quantities, on various occasions, with excellent results." Alfred R. Crain, M. D., New York City, April 24th. 1901, says: " In Chronic Asthma, especially in the Bronchial form of the disease, when inflammatory thickening of the membrane has taken place, the attacks persist for weeks. Familiar with the action of Gardner's Syrup of Hydriodic Acid as an alterative of the first rank, I treated all these cases by prolonged exhibi- tion of the drug in full doses until saturation was accomplished. Patients take it well, and I have no doubt the excellent results which I have obtained from its use will warrant a full trial of its merits by others who frequently meet this most stubborn and distressing disease." Almon H. Cook, M. D., Buffalo, N. Y., reports : " J. W., aet. 51, has suffered from Asthma during past five years, with usual symptoms. Began taking Syrup Hydriodic Acid (Gardner) in May, 1900, two drams in water, t.i.d., half hour before eating. In one mouth the paroxysms had become much less frequent and comparatively mild. Chronic Bronchitis. At the end of the second month they had disappeared en- tirely. He occasionally takes a botrle of Acid and the disease shows no signs of returning. In view of the fact that Asthma is a difficult condition to handle, I consider this case a fair sample of what Hydriodic Acid (Gardner) promises." 23 The most harrassing feature accompanying this condition is the hard and frequent cough, in prolonged paroxysms, caused by the tough, tenacious mucus and the effort to expel it. While these efforts are violent and exhausting, the amount actually expelled is inconsiderable. The greatest relief and comfort as well as permanent benefit and cure will accrue, if the secretions in the bronchial tract can be softened and liquefied to such an extent as to enable the patient to get rid of them. These secre- tions are the products of inflammatory action and perpetuate this condition by their presence. Syrup of Hydriodic Acid acts charmingly in these cases, greatly increasing the flow from the mucous surfaces. It may be used in either acute or chronic cases. The remedial action is necessarily slower in chronic cases, but the result is the same in the end ; the inflammation subsides, the mucous surfaces are re- stored to the normal condition and the disease is at an end. W. Gill Wylie, of New York, says : " I have had uniformly good results in the use of Hydriodic Acid in bronchitis." 3 W. C. Wile, A. M., M. D., Danbury, Conn., remarks: " Having under observation a chronic case of asthma compli- cated with chronic bronchitis, on which I had tried iodide of potassium, which was intolerable to the stomach, I put the patient, a woman of forty-nine years, upon Gardner's Syrup of Hydriodic Acid. The effect was all that could be desired. There was an almost immediate relief from the asthmatic conditions, rapid amelioration of the cough and decreased expectoration. The CHRONIC BRONCHITIS. 3 New York Med. Record, May 10th. 1879. Chronic Bronchitis. 24 sputum which was thick and viscid became thinuer in charac- ter, and after three months' use of the remedy, in increasing doses, till two teaspoonfuls were taken, three times a day, com- plete recovery took place, and from that time until her death of pneumonia, two years later, had no relapse." 4 F. R. Garlock, M. D., Racine, Wis., writes: "In my prac- tice I know of no better remedy in bronchitis, either chronic or acute." L. S. Nicholson, M. D., Washington, D. C., says: "The best success has attended the use of Gardner's Syrup of Hydri- odic Acid in bronchial disorders, scrofulous troubles, uterine catarrh, enlarged glands, and chronic rheumatism." Franklin B. Kaufman, Syracuse, N. Y., says: " I have used Gardner's Syrup of Hydriodic Acid with excellent success in a very aggravated case of chronic bronchitis after everything else failed. I consider it a wonderful remedy." W. C. Wile, A. M., M. D., Danbury, Conn., says :8 "In chronic bronchitis of long standing, Gardner's Syrup of Hydriodic Acid has produced most excellent results, and can be given when the iodide of potassium cannot for a moment be tolerated." S. T. Yount, M. D., Chicago, says:6 " Gardner's Syrup of Hydriodic Acid, a non-irritant prepara- tion, has a decided effect in chronic bronchitis. I have used it on myself and many patients, and have experienced almost immedi- ate benefit by the arrest of the profuse secretions and cough." Jas. A. Williams, M. D., New York City, says : " Gardner's Syrup of Hydriodic Acid is one of our best agents in bronchitis. It is also very efficacious in absorbing tu- mors, nodes and a variety of non-malignant growths, some of which may, in time, become malignant." HAY FEVER 4 Read before Am. Med. Assoc., Cincinnati, 1888. 5 New England Med. Monthly. 6 New York Med. Record. This troublesome affection, so widespread and obstinate to 25 Hay Fever, treatment, compelling the patient to flee from home, frequently in vain, to escape its tortures, will in most cases yield to treat- ment by Syrup of Hydriodic Acid. This remedy, acting as a germicide, eliminates the cause while by stimulating the entire mucous surfaces to increased secretion the congestion and in- flammation are relieved. William Judkins, M. D., late Professor Physiology, etc., Cincinnati College Medicine and Surgery, says :7 " I feel that I should be sadly derelict of duty did I not give to the profession, and through them to the laity, my successful treatment of this obstinate and distressing complaint. Mrs. has been subject to annual attack of Hay Fever for fourteen years. Last year she suffered an attack of bronchitis, during the latter part of the asthmatic stage, which came near proving fatal. The night of the 20th inst., difficulty of breathing set in to a limited extent. My attention had been called to a case of bronchial asthma which obtained relief from the Syrup of Hy- driodic Acid (Gardner), and I immediately ordered my patient to commence its use. The effect, in conjunction with counter irritation in the shape of Riggollot's mustard leaves at the wrist joints, was simply magical ; I can truly say that about every remedy suggested and recommended from the time that Bostock first wrote on the subject, 1819, had been tried, but nothing has ever given the relief and sense of comfort that this did." S. C. Martin, M. D., Professor Dermatology and Hygiene, Barnes Med. College, St. Louis, Mo., reports8 three cases of Hay Asthma, successfully treated with Gardner's Syrup of Hy- driodic Acid. " Case 1 had suffered for several years at the usual season. Had not obtained relief until frost. In two weeks patient en- tirely cured. Patient for more than a year has had no return of the attack. Case 2 had suffered for years during summer. No reap- pearance of the disease for over a year. 7 New York Med. Recotd, Sept. 6th, 1884. 8 St. Louis Med. Era, Sept., 1894. Catarrh. Case 3. In seven days patient restored to health. No return for over a year. In all these cases the Syrup was pre- scribed two weeks before the time for the expected attack, each season." Shoemaker recommends it in Hay Fever.9 26 CATARRH. Nasal, Bronchial, Pulmonary, Intestinal and Uterine. In this disease, as in bronchitis, there is an accumulation of tenacious mucus, adhering to the walls of the mucous surfaces, which is too thick and clinging to be readily detached. The obvious remedial measures must be, first, to reduce the inflam- matory action, which has been the immediate cause of the morbid secretion ; second, to promote the removal of this morbid secretion, by stimulating the mucous surfaces and liquefying the secretion in the parts involved ; third, to destroy if possible, any germs which may have become located in the parts, by the administration of an antiseptic and germicide. All of these desirable objects are attained by the use of Gardner's Syrup of Hydriodic Acid. The effect of this remedy in bronchial and nasal catarrh, is to cause almost immediate re- lief from the hard and exhausting cough, produced by the effort to dislodge the clinging mucus in the nasal passages and bronchi; to render expectoration easy, to open the air passages and to render the breathing free and natural; to reduce the inflamma- tory action, thus preventing renewed accumulations of morbid products, and then by its continued use in smaller doses, to keep up the alterative and germicidal action until the parts have been restored to a normal condition. The late Henry M. Field, M. D., strongly recommends it in bronchial and pulmonary catarrh.10 F. R. Garlock, M. D., Racine, Wis., reports : " I have pre- scribed Gardner's Syrup of Hydriodic Acid in a variety of catarrhal affections; I have used it as a constitutional remedy in 9 Medical Bulletin, Aug., 1889. 10 New England Med. Monthly, Oct., 1890. 27 Pleurisy-Pneumonia. vaginitis, urethritis and catarrhal affections of the intestinal tract. In these situations I have derived most decided effects. It changes the nature of the secretion ; where it was offensive, it becomes innocuous. It acts as a disinfectant. It is almost a specific in the catarrhal affections of children, especially those which occur during the winter months. All about the great lakes of the northern United States these affections prevail to a great extent, and the fatality from these sources is very high. The most delicate stomachs are not nauseated by the syrup." J. C. Wilson, M. D., Edinboro, Pa., April 5th, 19O1, re- ports : "I have been highly pleased with results from Gardner's Syrup of Hydriodic Acid in a case of Chronic Catarrh of the nasal passages as well as of the bronchial tubes. The case was that of my own daughter, who had been suffering from a very obstinate form of Vaso-Bronchial Catarrh, a sequellaof a protracted attack of measles, followed by Diphtheria, the whole lasting for a period of weeks. I am a practitioner of more than fifty years, and take pleasure in recording my testimony in favor of Gard- ner's Syrup of Hydriodic Acid." Frederick H. Brand, M. D., Moline, Uis., says: " I have used Gardner's Syrup of Hydriodic Acid very ex- tensively in catarrh and have found nothing which proved so satisfactory." PLEURISY AND PNEUMONIA. Dr. L. G. Pedigo, Leatherwood, Va., gives a history of his own case. He was under treatment by eminent authorities in New York, and was told he would be compelled to winter in the south and leave his practice. But under the action of this Syrup, he not only continued his practice, but to the surprise of his physicians and himself it was found that he had so far recovered that the advice was reconsidered and he was allowed to stay. His condition was a sub-acute attack of pleurisy. The doctor recommends it particularly in pleurisy with abundant serous effusion; the problem being to get rid of the Pleurisy-Pneumonia. 28 effusion and to prevent its re-accumulation. He says: "As a result of very positive clinical experience in a very large number of cases in the last twelve months, my practice is to perform paracentesis and give a course of Gardner's Syrup of Hydriodic Acid, as after treatment. In fact, if the operation is not too urgently indicated, I usually begin the use of the Acid in ad- vance, so as to have the patient's system somewhat under its in- fluence when the operation is done. "Under this plan of treat- ment I have never had to tap a second time but once and never a third time in a single instance. This treatment has produced, by far, the most satisfactory effects I have ever secured in pleur- isy with effusion. Not only does re-accumulation seem to be prevented, but temperature is controlled, and I find no evidence of degeneration of the remnant of effusion-an occurrence which has always been one of the serious dangers of the operative treat- ment in such cases." In Acute Pneumonia there seems to be a very positive indi- cation for Hydriodic Acid ; the condition is a septic one-there is a necessity to cause resorption of the accumulation in the lung ; the well known sorbefacient and antiseptic influence of iodine is here indicated without a question ; it also facilitates expectora- tion remarkably. Numerous cases have been reported of acute pueumonia in which complete recovery followed this treatment. The dose ad- ministered was two teaspoonfuls, well diluted, every three hours, or oftener, p. r. n. W. H. Bentley, M. D., Woodstock, Ky., reports: 11 "Called at io o'clock a. m., Nov. ii, to see J. T., set. 19 years; found him with badly furred tongue, pulse 150 and full, temperature 103.5. He complained greatly of pain in right thoracic region, coughed almost incessantly, and raised a large amount of bloody sputum. Auscultation and percussion showed that the entire anterior surface of the right lung was involved. Another physician was present ; he told me, unhesitatingly, that the patient was bound to die. At 12 o'clock, noon, I administered ji Medical Summary. Spasmodic Croup. a dessert-spoon full of Syrup Hydriodic Acid (Gardner), mixed with two fl. ounces of water. I repeated the dose at one and three o'clock p. m., directing a similar dose every three hours during my absence. I returned next day at noon. The tongue had greatly cleared of its furred appearance. The pulse had lost its rigid feel, and beat softly at 100. I did not take the temper- ature. The cough was not harrassing, and the sputum was rust colored. Complained of little pain. Continued medicine at intervals of four hours. Saw him 14th at 3 p. m. ; all the symptoms had improved, but there was marked exacerbation of fever at night. Directed medicine con- tinued at intervals of four hours, each dose followed in two hours by five grains sulphate of quinine in absence of fever. I did not see the case again, but the patient made a rapid and complete recovery. I have used the Syrup Hydriodic Acid (Gardner) in twenty- three cases of acute pneumonia, and always with good results." Wm. H. Wehner, M. D., Germantown, Pa., March 27th, 1902, says: " In cases of tardy resolution following pneumonia, I have come to depend on Gardner's Syrup Hydriodic Acid as an effi- cient and necessary adjunct to prompt and successful recovery." 29 SPASMODIC CROUP. J. Stinson Harrison, M. D., Washington, D. C., says:30 " I was called at night to see a child two years old, with severe attack of spasmodic croup. The child had been suffering all day ; had used all the ordinary croup remedies with no avail; the father thought his boy would die, and I told him I feared he would, but would do all I could for him. I gave him a small teaspoonful of Gardner's Syrup of Hydriodic Acid in a little water. At the end of the first hour the child seemed somewhat relieved ; I then repeated the dose, and at the end of the second hour the child was decidedly improved, passed the night com- fortably, and the next morning was up, playing about the room. 30 Medical Mirror, Aug., 1891, La Grippe. It is now my main reliance in every case of croup, and in ' la grippe ' I always use it with advantage. I am using it to my entire satisfaction in nearly all cases involving the breathing apparatus, particularly croup, laryngitis, asthma, and bronchitis; the more I use it, the more highly I value it. I hardly know how I should get along without it.'' J. M. Blakesby, M. D., Germantown, Ky., says: " Gardner's Syrup Hydriodic Acid seems to be all you claim for it in the treatment of asthma and croup. I consider it an ex- cellent remedy.'' 30 LA GRIPPE. The antiseptic properties of Gardner's Syrup of Hydriodic Acid are especially useful in this disease, acting as a germicide, reducing temperature, and preventing, if used in time, the ob- stinate bronchial cough which accompanies the disease, by allay- ing inflammatory action. It is also very serviceable in the sequelae, particularly the nervous symptoms. Q. A. Bridges, M. D., Guilford, Me., says: "Since La Grippe left us last winter I have been called to several patients who complain of having pain and a pricking sensation, in their upper or lower extremities, or both, not unlike that of a foot be- ing * asleep ' and growing more and more unendurable from week to week. Having tried nearly everything, and meet- ing only with failure, I at last hit by mere chance, upon Gard- ner's Syrup of Hydriodic Acid, and am delighted to say it was a great success. I have given it to two patients, both of whom are over .fifty years of age, in doses of twenty drops to half a dram, before meals, and the disagreeable symptoms I have de- scribed are all gone. ' ' C. L. Dodge, M. D., Kingston, N. Y., reports two cases of La Grippe, where it was used in the latter stages, with best re- sults. 12 Samuel R. Nissley, M. D., Elizabethtown, Pa., April 26th, 1901, reports : "During the recent siege of La Grippe I have had the 12 Practitioner's Monthly, Aug., 1889. Rheumatism. most gratifying results from the use of Gardner's Syrup of Hydriodic Acid. When there was a general dyscrasia of the system I used the Syrup of Hydriodic Acid for its tonic and alterative effects, which were prompt, effectual and decisive in a majority of my patients." P. L- Hilsman, M. D., Albany, Ga., March 26th, 1902, says: " I have had frequent attacks of La Grippe, which has each time left me with some thickening and chronic irritation of the air passages, and I have always obtained relief from Gardner's Syrup Hydriodic Acid." J. C. Campbell, M. D., Denmark, N. C-, says: " For the last eight years I have had attacks of La Grippe, and it always centered itself on the bronchial tubes, and every attack was more violent than the preceding. I do not think I could have recovered from my last attack had it not been for Gardner's Syrup Hydriodic Acid. It is not necessary to give the details of my symptoms. It will suffice to say that I had used all the remedies in the books and Medical Journals without effect. The first day I used this syrup the stringy mucus was loosened and I could expectorate it without effort. My appe- tite improved and in two weeks I was well. I have had no cough and have been well ever since. I have had ten cases similar to my own and they all recovered under the same treat- ment." 31 Acute Inflammatory Rheumatism, Chronic Rheumatism, Gout. These diseases are doubtless caused by the retention of va- rious retrograde toxic products and their absorption into the or- ganism, due to defective elimination, faulty condition of organs of excretion, or both. A constitutional septic state is thus pro- duced, which impairs natural functions, and causes congestive engorgement. The most reasonable treatment to relieve these conditions should naturally suggest itself. Rheumatism. 32 Tlie excretory channels should be opened and freed from ob- struction to the utmost, that the accumulation of toxins be ar- rested ; the prevailing septic condition should be combated by the use of such antiseptic treatment as will restore the circulation and tissues to an aseptic state, without injury to the organism or its functions. Syrup of Hydriodic Acid (Gardner) is an ideal remedy in these conditions, all of its medical properties being actively em- ployed in removing the morbid state. Its alterative, sorbefacient and antiseptic properties are all indicated ; the urinary tract is rendered aseptic and freed from in- flammatory exudates ; secretions are increased and liquefied ; and such products as are not eliminated directly, are rendered innoc- uous, in which case they are absorbed without injury to the pa- tient. In the acute form, the duration of the disease is shortened, pain relieved, and temperature reduced in a much shorter time than by other measures, while the heart is free from complica- tions, as the remedy prevents the exudation of plastic material. It should be given at once, without regard to the fever, and pushed, that the alterative action be obtained in the least possible time ; doses of one tablespoonful properly diluted with half glass of water, may be given every three hours until relief is obtained. In the chronic form of this trouble the dose should not be so large, reliance being placed upon the gradual sorbefacient action of the remedy upon the accumulated aggregations of toxic mate- rial in the tissues, the eliminative effect of increased flow of secre- tions and the antiseptic action of the remedy, all of which re- quire a much longer time than in acute cases. These last remarks apply equally to Gout. The late Janies Craig, M. D., of Jersey City, N. J., reports sixteen cases of acute rheumatism. He says :13 " Its effects have been most prompt in acute inflammatory rheumatism, re- lieving pain in from twelve to forty-eight hours. I have been called to see patients found with high fever, joints swollen, and suffering terribly, and on the following day have been agreeably 13 N. Y. Med. Journal, Aug. 8th, 1883. Rheumatism. surprised at their rapid improvement, finding them in a great measure free from pain and fever reduced. I prescribe, for adults, two to three teaspoonfuls in water, every two or three hours until relieved ; afterwards I reduce the dose to one teaspoonful." S. T. Yount, M. D., Chicago, Ills., states:32 "Gardner's Syrup of Hydriodic Acid has been used with the best results in chronic rheumatism. Two cases, one of one year, and another of six years' standing, were cured in a month's time. The case of six years' standing had resisted all remedies, and the patient was bed-ridden about half of the time. It produced no gastric irritation whatever. ' ' W. T. Peyton, M. D., Louisville, Ky., reports: "I cannot find words enough to praise Gardner's Syrup of Hydriodic Acid. It answers every indication in acute and chronic rheumatism." Lewis G. Pedigo, M. D., Leather wood, Va., reports: "Ten- dency to pleurisy is associated with a tendency to the development of muscular rheumatism, and finds its exciting cause in the pe- culiarities of a ' Rheumatic climate.' Bring together then a ' Bilious rheumatic diathesis ' and a climate of this character, and the chances are largely in favor of pleurisy as a result. After years of patient research and experience, I find nothing which will remove the predisposing cause with such certainty and dispatch as the continuous use of Gardner's Syrup of Hydri- odic Acid in moderate doses." F. R. Garlock, M. D., Racine, Wis., reports: "Gardner's Syrup of Hydriodic Acid in rheumatism, comes as near being a specific, as quinine in intermittent fever." Edwin T. Randall, M. D., Brooklyn, N. Y., April 19th, 1901, reports : "I have prescribed Gardner's Syrup of Hydriodic Acid of late in chronic rheumatism with very gratifying results. In one case the patient has been practically an invalid for over a year, and yet to day this man visits my office instead of my calling at his home." 33 32 Medical Waifs June, 1890. Syphilis. 34 William S. Stoakley, M. D., Cheriton, Va., April 23d, 1901, reports : " In rheumatic affections, when iodide of potassium is usually given, I find Gardner's Syrup of Hydriodic Acid quite as effectual and far more pleasant." Syphilis. No more searching test of the efficacy of Gardner's Syrup of Hydriodic Acid, as representing the perfection of physiological requirements in the application of iodine to internal treatment, can be conceived of, than is afforded by the following experience. For years, indeed throughout the past, iodides of sodium or po- tassium have been wholly relied upon in the treatment of syphil- itic lesions, as an alterative and sorbefacient. They have been the only forms of iodine which, in the past, have acted satisfac- torily in these profound and complicated conditions. In their use it has been found necessary to administer them in heroic doses to accomplish the desired results. This has been attained at the cost of the vitality of the patients, as the depressing con- sequences of such large and long continued dosing is always a marked feature of treatment, and frequently causes the suspen- sion of the remedy at the very time that its continued use is the most imperative. It is remarkable in connection with these cases that the results have been secured with only ordinary doses of the Syrup of Hydriodic Acid, instead of the large quantities found necessary in the use of the alkaline iodides, and that the results have been secured with no inconvenience to the patients. When critically examined, this shows that iodine in the form of Hydriodic Acid is more active, more assimilable, and produces better physiological results than the alkaline iodides. If success' ful in this class of cases, no further argument is necessary to con- vince the most skeptical that this preparation should be used, in preference to the iodides, in all instances where the alterative, sorbefacient, and general constitutional action of iodine is re- quired. The late Arthur E. Mink, M. D., Prof. Mental and Nervous Syphilis. Diseases, College Phys, and Surg., St. Louis, Mo., reports 58 cases of Syphilis of Nervous System successfully treated during one year. He says :14 " Gardner's Syrup Hydriodic Acid has all the advantages and none of the drawbacks of the Iodides of potassium and sodium. It agrees better with the stomach, has no depressing influence on the heart, and produces no skin eruption. I have been using it for the past two years with the most gratifying re- sults." In an address upon " Syphilis of the Spinal Cord," Dr. Mink also says:-15 " Mercury, the grand destroyer of syphilitic growth, induces destructive tissue change in these morbid products (leutic neo- plasms in and around the cord) ; and Iodine, by stimulating the activity of the lymphatic and glandular apparatus, removes the debris from the organism. Most patients of this class are afflicted with cardiac and gastro-intestinal irritability, and for this reason I have long since ceased to torture my patients with the iodides of sodium and potassium, and have been using Gardner's Syrup of Hydriodic Acid in their place with the utmost satisfaction. I find it just as efficacious, and much more agreeable than the iodides and the other preparations of Hydriodic Acid. It can be given before meals, the best time for absorption. It can be con- tinued for a long period without any ill effects. There is no pre- paration more widely substituted than this by unscrupulous drug- gists, but in my exerience, no other preparation has had the same beneficial results." In syphilis in the latter stages, when Iodine is depended upon to bring about the elimination of the mercuro-syphilitic toxin, necessarily formed as a means to an end in the previous treatment, Syrup of Hydriodic Acid is unequaled. No other form of Iodine is so well tolerated, so active, as this Syrup. In its use it is not necessary to give the heroic doses usual with po- tassium iodide. Ordinary, or slightly larger doses than the nor- 35 14 Jour. Am. Med. Assoc., July, 1897. 15 Read before St. Louis Academy of Medical and Surgical Sciences, Jan. 18th, 1898. Syphilis. 36 mal, if given with regularity, accomplish all the results desired, with no unpleasant symptoms to the patient. The anaemia, con- tinuous headache, sore throat, and glandular swellings disappear under its use. It heals the mucous and serous membranes, espe- cially the tonsils and throat. The fact that it is a pleasant remedy, tolerated by all, that it is infinitely more active and efficient than the alkaline iodides, that none of the unpleasant symptoms which follow the use of iodide of potassium are ever observed, that digestion remains un- impaired, is being thoroughly appreciated by the profession, es- pecially in the treatment of this disease. It is remarkable how many physicians are now replacing iodide of potassium with Gardner's Syrup of Hydriodic Acid, and acknowledging the superiority of the latter in all applications of iodine to internal treatment. J. V. Shoemaker, A. M., M. D., the eminent specialist, of Philadelphia, Pa., speaking of its use in syphilis, says: -33 ' ' Probably the greatest value to the practitioner of Syrup of Hydriodic Acid will come from its employment in syphilis, par- ticularly in the latter stages. The stomach is often rebellious at this time, for it has most likely been surfeited with mercury. Many cases drag along under iodine because not enough of it can be borne, and mercurials are not only useless, but at times injuri- ous. Instances such as those related bear large doses of Syrup of Hydriodic Acid admirably. Some cases have come under my observation in which the patients were at a standstill, who at once brightened up and rapidly improved under the use of Syrup of Hydriodic Acid. If thought desirable, the biniodide of mercury (the red salt) can be combined with the Syrup, but the protiodide (the green salt) cannot be used at the same time because it would be con- verted into the former salt, and, unless care was taken, the un- expected activity of the Syrup thus prepared would exceed the prescriber's expectations, and possibly injure the patient. In syphilis, the Syrup can be pushed, if needed, until the 33 Medical Bulletin, Aug., 1889. Syphilis. characteristic saturation is evident, or when the metallic taste becomes pronounced, and we know that iodism is at hand. It is advisable, however, not to carry the administration too far." W. C. Wile, A. M., M. D., LL.D., Danbury, Conn., says: " In all the latest stages and manifestions of syphilis, Gardner's Syrup of Hydriodic Acid has yielded its most magnificent results. Pleasant to take, rapidly pushed to large doses, I have found the most pronounced and favorable effects. Patients take it readily, and the improvement is so rapid and immediate, that they need no urging to continue its use for as long a time as the doctor deems desirable. " 16 A.»Rose, M. D., Lebanon, Ky., says:31 ''I have tested it in all forms of syphilis-primary, secondary and tertiary. In the latter, there are but few manifestations of the disease after having used Gardner's Syrup of Hydriodic Acid. I have used it in syphilis, where anaemia was marked, when neither potas- sium iodide, syrup iodide iron, or mercury in any form could be tolerated for one moment; anaemia disappeared, the continuous headache instantly ceased, sore throat got well at once, all gland- ular swellings disappeared." John W. Murphy, M. D., Sullivan, Ind., says: "Gard- ner's Syrup of Hydriodic Acid is all right as a substitute for iodide of potassium. I have had splendid results in syphilis, acute inflammatory rheumatism, eczema, nasal catarrh, acute pneumonia, and conjunctivitis neonatorum." S. A. Binion, M. D., N. Y. City, reports a case of syphilis. " My patient is progressing rapidly and the syphilitic eruption on his face has nearly disappeared ; he suffers no more from dis- tressing headache, and is cheerful; he is now on the fourth bot- tle of Gardner's incomparable Syrup of Hydriodic Acid, and judging from results already obtained, I do not hesitate to say that one or two bottles more will accomplish the desired effect. When I first met him, his face, especially the nose and around the eyes, was swollen and fiery red. I treated him upon general 37 16 Read before Am. Med. Association, 1888. 31 Medical Mirror, July, 1892. Syphilis. 38 principles and kept the ' enemy at bay ' until I adopted Gard- ner's Syrup of Hydriodic Acid, not as an adjunct or adjuvant, but as the principal means." This case subsequently reported well. C. F. Mitchell, M. D., C. M., Cleveland Ohio, gives the following clinical history, June 6th, 1901: " F. H. Age, 41, Occupation, Civil Engineer, consulted me Jan. 31st, 1900, relative to a sore upon his penis; upon exami- nation I found a well developed Hunterian Chancre upon the Corona glandis, and the inguinal and femoral glands were hard and shotty to the touch. An examination of the throat revealed slight ulcerated spots on the left tonsil, and a projected, inflamed area upon the left side of the pharynx about the size and shape of half a dime. I diagnosed his case as Syphilis in its primary stage. I gave the usual advice relative to the use of intoxicat- ing beverages, and advised the use of non-acidulated waters and the restricted use of tea and coffee, instructing him to total ab- stinence of sexual intercourse, and advised the use of very mod- erate exercise in the open air, keeping his thoughts as much as possible from the animal by the perusal of literature placed in a moral category. I began the medicinal treatment with Bin-Iodide of Mercury, one-eighth of a grain, three times daily, and inunctions of Blue Ointment, one dram rubbed in the groin every other night at bed-time. I dressed the primary sore with 1-1000 of Bi-Chloride Mer- cury, and when dry I applied Aristol powder freely, and gave him a gargle of Potassium Chlorate, fluid extract of Hydrastis and Eisterine. I kept him under the above treatment until slight symptoms of salivation appeared, then I discontinued the use of all mercurials and placed him upon Syrup Hydriodic Acid (Gard- ner) in one dram doses, t.i.d., for a period of one week, then I increased the dose of Syrup Hydriodic Acid to two dram doses for the following week, and afterwards administered 1-16 grain of Bin-Iodide of Mercury in conjunction with two dram doses of Syrup Hydriodic Acid, t.i.d., one half hour before meals in Syphilis. 39 water. I also prescribed 1-2000 Bi-Chloride Mercury as a bath to the genital organs and lower extremities twice a week, applied at bed-time, and advised the use of a Turkish bath about once in two weeks, keeping him on this treatment for about two months until indications of anaemia were manifest, then I dropped the mercurials entirely and used Syrup Hydriodic Acid, one dram, Fowler's Solution one minim, t.i.d., one half hour before meals, in water, and a tablet triturate of Pyrophosphate of Iron, Quinine and Strychnine, regulating the bowels with Cascara Sagrada and Podophyllin at bed-time, followed by Rochelle salts the next morning before breakfast. By such treatment his digestive functions were impaired but slightly. The primary sore disappeared entirely, and the glands assumed their normal size, there being no manifestations of former inflamed areas in the throat. He experienced a slight eruption on forehead and temporal regions, but I attributed this to physiological action of treatment. The prominent anaemic symptoms, such as cold hands and cold feet ceased, and I still kept him off of all mercurials except the Bi-Chloride baths and continued the use of Syrup Hydriodic Acid in one dram doses with one minim of Fowler's Solution, t.i.d. alternating with a general tonic, consisting of Pepsin, Extract of Malt, Nux Vomica, Tinct. Gentian Co., Glycerine and water, which treatment I continued for about seven weeks until he ex- perienced a marked metallic taste, then I decreased the dose of Syrup of Hydriodic Acid, which he seemed to bear nicely, with- out any manifestations of lodism, and he has taken said treat- ment at irregular intervals since. He finally left the city, but I talked with him recently and he states that there is not a spot, blemish or any external manifestation of the disease that his most intimate friends can discern, and during his absence from this city he has been treated for acute colds by prominent physi- cians who could not detect any symptom of his past disease, and without solicitation he has expressed his gratitude in the most impressive language. I attribute the excellent results obtained as due principally Syphilis. 40 to the use of Syrup Hydriodic Acid (Gardner), obtaining its therapeutic value without deranging the system or creating a tissue waste, as certainly would be the result by the use of Iodide of Potassium " Thomas H. Manley, M. D., New York City, at his Surgical Clinic, Harlem Hospital, says : 11 "Gardner's Syrup of Hydri- odic Acid is the ideal way of exhibiting iodine. I always use it, in preference to any other remedy, to tone up the system in per- sons of strumous, syphilitic or tubercular tendencies, before operations. Indeed, in most cases, its timely and appropriate employment would obviate the necessity of any sort of surgical interference. ' ' Samuel Robinson Nissley, M. D., Elizabethtown, Pa., says: 18 " I prescribe Gardner's Syrup of Hydriodic Acid almost ex- clusively in those cases where an alterative is indicated, without subjecting the patient to that depressing course of medication, the persistent and long-continued use of mercury and Iodides. In the various phases of syphilitic infection I have used it with great effect. Case i. Mr. F. set. 6o. This patient is a victim of syphi- litic contamination ; disease has reached the tertiary stage. He had been thoroughly mercurialized, had taken some iodide of potassium, but his stomach revolted. I prescribed Syr. Hydriodic Acid (Gardner), and he is im- proving and gaining in flesh under its use. I have directed the patient, when taking the Syrup Hydriodic Acid (Gardner), tore- tain it in the mouth a few minutes before swallowing, so that it shall remain in contact with the sticky secretions of the throat. I find it to be an excellent solvent for the thick and gluey secretions so characteristic of this disease, and the patient soon experiences relief from the constant disposition to clear the throat. Case 2, male, set. 21. Hereditary syphilitic infection; Parotitis, general glandular enlargement, ozaena, with ulceration 17 Surgical Clinic, Harlem Hospital, Oct. 19th, 1893. 18 Medical Sentinel, Aug., 1900. Syphilis. 41 of pituitary membrane. He took three teaspoonfuls of Syr. Hydriodic Acid (Gardner) four times a day. He has taken 16 fl. ozs. of this syrup with no complaint of any disagreeable symp- tom. When I first saw the patient there was a metastasis in- volving the left testicle. Warm applications to the neck and the use of Syr. Hydriodic Acid soon translated the disease to its ori- gin, the parotid gland of the corresponding side of the body." J. V. Cleaver, M. D., Akron, Ohio, June 16th, 1901, re- ports : " I have been using Gardner's Syrup of Hydriodic Acid for over 10 years, and have found it always reliable and the same. I find that in most cases where Iodide of Potassium is indicated that this Syrup is preferable, inasmuch as it is more agreeable to take, is not so hard on the stomach, and its action is much quicker. In Syphilitic and Strumous subjects it is practically as near a specific as we have, as might be said also as regards Chronic Joint and Rheumatic subjects. It also relieves many Asthmatic troubles in a short time. I find it a very reliable preparation in the affections men- tioned." Elbert E. Fisher, M. D., Rodney, Iowa, May 6th, 1901, reports : " I used Gardner's Syrup of Hydriodic Acid in a case of Syphilis with splendid success ; in fact, I consider Gardner's Syrups superior to any I have used. They seem so uniform in composition." Report from the Suffolk Hospital, Boston, Mass., Dec. 31st, 1901 : "Case 1. Otto Neilson, aged 27, occupation sailor. Dis- ease Syphilis, contracted in Loudon, came to this country in a sailing vessel, had a hard, stormy passage, the vessel being de- tained by head winds and ice. While on shipboard he received no treatment whatever, and when admitted to the Dispensary his general condition was very bad. On examination, well marked chancres were found, and Syphilis. 42 the glands (femoral and inguinal) were found hard and swollen. Throat and mouth sore and in ulcerated condition. Stomach very irritable, so much so that only liquid food in small quantity could be borne. Abdomen tense and hard and covered with patches; bowels constipated ; suffered considerable pain all over the body, and was in thin and emaciated condition. The patient was ordered to bed and to be bathed twice a day in a weak hot solution of sulpho-napthol. The irritability of the stomach over- come by proper treatment, liquid food, nutritive enemas per rec- tum, etc., mouth was swabbed three times a day with a mixture of Tr. Chlor. Iron, Chlor. Potass. Glycerine and water. Light inunctions of mercurial ointment inside the thighs twice a week. Fifteen drops of Syrup Hydriodic Acid (Gardner's) in one-half glass of water, four times a day were then given. The chancres were kept clean and dusted twice a day with a mixture of Ace- tanilid and Boracic Acid. Under this treatment improvement began to take place, throat and mouth cleared up, chancres soon healed, stomach became normal. The Syrup Hydriodic Acid (Gardner's) was then increased to two teaspoonfuls t. i. d., with the addition of one-sixteenth of a grain of Biniodide of mercury ; this was continued until a slight disturbance of the stomach was noticed. The mercury was then discontinued, and the treatment with Syrup Hydriodic Acid alone employed. Improvement wTas rapid, and in a short time he was discharged, practically cured. He was directed to continue the use of the Syrup Hydriodic Acid (Gardner's) for three months. Five months after he came to the Dispensary and there had been no return of the disease." C. H. Wallace, M. D., St. Joseph, Mo., Jan. nth, 1902, reports: "I have been an extensive prescriber of Gardner's Syrup of Hydriodic Acid for years. I use it almost to the ex- clusion of Iodide of Potassium in specific trouble. I find many patients who can take this, who will not tolerate the Iodides in any other form." L. J- Morton, M. D., Attending Neurologist to St. Mary's General Hospital, Brooklyn, N. Y., in a paper on " Intracranial Syphilis and Hemiplegia, with Report of the Cases Treated in Genito-Urinary Diseases. St. Mary's General Hospital, Brooklyn," remarks as to treat- ment i19-"What do I do when the patient cannot tolerate potas- sium iodide? You will find the Syrup Hydriodic Acid a good substitute, or you may use it altogether in doses of from two to four teaspoonfuls in plenty of water (a large goblet full) three times a day. Be sure to insist on your patients drinking large quantities of water when taking." William E. Thomas, M. D., Brooklyn, N. Y., Apr. nth, 1902, says: "Gardner's Syr. Hydriodic Acid is well borne when the alkaline iodides cannot be tolerated at all. I used this syrup in a cerebral gumma, which with mercurial inunctions saved the man's life. The slightest amount of KI could not be tolerated." H. E. Houston, M. D., C. M., Kalispell, Mont., Apr. 30th, 1902, says : " I have had the best of success in treating many cases of Syphilis with Gardner's Syr. Hydriodic Acid." 43 Genito-Urinary Diseases. There are several peculiar conditions of this character, in which no form of iodine heretofore employed has been found applicable, viz., chronic nephritis, pyelitis, and tubal disease of the ovary. These conditions all involve considerable inflamma- tory action. Wherever this is the case there is a consequent deposit of the products of inflammation. This not only clogs the excretory passages but also produces a septic condition which, by absorption, poisons the system. The iodides of sodium and potassium are productive of so much irritation that they cannot be used in these cases for the antiseptic effects of Iodine. In fact, the internal antiseptic action of Iodine, valuable as it is known to be, has never been available until Gardner's Syrup of Hydriodic Acid was introduced. This preparation, being perfectly non-irritant, is at once absorbed, if administered upon an empty stomach, and produces all the well known antiseptic 19 Read before the Brooklyn Medical Society, Feb. 12th, 1901. Genito-Urinary Diseases. 44 effects of iodine, internally, which the experience of the surgeon has demonstrated in its external use. Dr. Ferd. King, New York, reports a case of uric acid diathesis (renal calculus) entirely cured by Gardner's Syrup of Hydriodic Acid. Commenting upon this remedy, he also re- marks : " I prescribed Gardner's Syrup of Hydriodic Acid in a case of chronic nephritis five days ago, and the patient reported to-day, ' all symptoms have disappeared.' It is the remedy, par excellence, for diseases of the kidneys caused by excess of uric acid. I want the profession to know what Syrup of Hydriodic Acid will do in kidney troubles. A trial in these cases will con- vince the most skeptical." George Frederick Laidlaw, M. D., of New York City, on September 28, 1898, writes as follows: " For over two years I have been using your preparation of Hydriodic Acid and find it the most active and elegant prepara- tion of iodine that I have ever used. I have used it in urinary work, carefully controlling the action by repeated urinary analyses, and I am delighted With the uniformity and certainty of its action. In cases of renal torpor, I have repeatedly increased the excretion of urea and phosphates by the administration of Gard- ner's Syrup of Hydriodic Acid, in doses of one dram three times daily. In chronic constipation, it is curative. In croupous pneumonia, Hydriodic Acid will promote resolution." W. B. Fletcher, M. D., Indianapolis, Ind.', reports an inter- esting case of pyelitis complicated with cystitis.80 "T. A. A., war veteran, forty-seven years, weight 87 pounds, skin rough- ened in patches, particularly over the chest, in spots from size of a dime to that of the hand. Tenderness over the ascend- ing and descending colon and some pain in pressure over the loins Ophthalmic examination showed extremely contracted pupil ; under atropia dilation, the optic disc was found con- 20 Charlotte Med.'Journal, Nov., 1894. Genito-Urinary Diseases. 45 gested, the arteries varicose. Chemical and microscopical exam- ination of the urine-found loaded with pus, epithelium from the pelvis of the kidneys, a few granular casts and a large quantity of bladder epithelium. Prescribed hot baths and friction ; blad- der washed with saturated boric acid solution every third morn- ing and Gardner's Syrup of Hydriodic Acid before meals. The results were in one week a gain of two pounds in weight, a nor- mal pupil, a clear skin, a gradual diminishing headache, a better feeling in loin and legs. Improvement continued. In three months he weighed 112 pounds and says he feels well, some- thing never experienced since the close of the war. I regard the cure of this case due to the Hydriodic Acid, as its tonic alter- ative properties upon the sympathetic system have been so fre- quently demonstrated in my own practice, whenever the glandu- lar organs were at fault, or defective nutrition caused degenera- tion of the vaso-motor centres, as in exophthalmic goitre, chronic tabes, mysentericus, etc, I prefer Gardner's preparation to any I have used as being less liable to produce irritation of the stomach, or cause headache, as many other preparations do." A. Rose, M. D., Lebanon, Ky., remarks:21 "There is a wide field of usefulness for Gardner's Syrup of Hydriodic Acid that so far, has been little dreamed of, viz. ; in tubal disease of the ovary, leucorrhcea and membranous dysmenorrhcea. My experience in gynaecology, and the success following the use of this remedy, proves conclusively that this preparation will excel every other preparation now known in the above complaints. I unhesitatingly recommend it to my brother physicians, and can readily see its superiority to iodide of potassium and that it will largely supplant the latter as a means for the internal assimila- tion of iodine. Upon trial the reason will be apparent and only equal the astonishment at the result obtained by the remedy itself. This is the only preparation on the market I have any faith in." Geo. H. Millington, M. D., Rockport, Texas, April nth, 1902, says : ai Medical Mirror, Julj, 1892. Lead Poisoning. " I could not get along without Gardner's Syrup of Hy- driodic Acid. I have a patient on it now, over eighty-six years old, with hypertrophy of prostate gland. Its action in this af- fection is remarkable." C. E. Belcher, M. D., Clearfield, Pa., March 31st, 1902, savs: " Nearly a year ago I met with success in the treatment of catarrh of the bladder by the use of Gardner's Syr. Hydriodic Acid, but I desired to test it more fully. I can now from ex- tended experience in the use of this elegant preparation in the treatment of that troublesome and at times persistent condition, state most emphatically that it is a specific. This is strong, but I have not met with failure in a single instance. In any catarrhal state Iodine is a most valuable ad- junct in treatment, but in its action upon the mucous membrane of the urinary tract, Gardner's Syrup of Hydriodic Acid is un- equaled. I have cured cases by it after repeated failures with the old methods, and local treatment." 46 Poisoning by Lead, Mercury or Arsenic. No remedy has been found so promptly and thoroughly curative in these conditions as Gardner's Syrup of Hydriodic Acid, with free use of saline cathartics. These two remedies should not be administered together, a sufficient interval should be allowed between the respective doses. The wrist drop and chronic abdominal pains yield promptly to this treatment. The facility with which the Hydriodic Acid combines with these metallic poisons ensures their rapid elimination. In cases of lead poisoning, lead may be detected in the urine a short time after its administration. The elimination of lead, however, is quite rapid, and if this remedy is too freely administered it may cause an increase of the characteristic symptoms by rendering the metal lodged in the tissues soluble, and consequently active. While it is the best remedial measure, its use should be care- fully watched and the dose graded to the tolerance of the patient. Fibroma. The same remarks apply to the treatment of arsenical and mercurial poisoning. W. C. Wile, A. M., M. D.,says:34 " While practicing at Sandy Hook, Conn. I had the oppor- tunity of observing its action in lead poisoning in a great many cases, lead entering largely into the compound which is mixed with the crude rubber during the process of manufacture. I de- pended almost entirely on the Syrup of Hydriodic Acid for all forms of chronic lead poisoning. In lead paralysis this remedy, combined with keeping the bowels quite free, and the application of the faradic current, were the only means employed, and always with satisfactory and oftentimes surprising results. Wrist-drop and chronic abdominal pains would yield to the remedy, combined with saline cathartics." The late Louis Lewis, M. D., M.R.C.S., Philadelphia, Pa., says: " I have found Gardner's Syr. Hydriodic Acid of great value in lead poisoning with wrist-drop." 47 Fibroma. Fibroid Tumors. In these conditions the prevailing method of procedure is almost universally operative. The average practi- tioner who is not biased in favor of surgical interference and who is willing to weigh absolutely demonstrated facts in the medicinal treatment of these affections, will be pleased to know that the suc- cessful results attained by the use of Gardner's Syrup of Hydri- odic Acid in these cases has been thoroughly authenticated. The effect of the treatment is to cause these tumors, wherever located, to shrink and become innocuous. Many instances of this result have been published in the experience of physicians of such good standing that the truth of this statement cannot be denied. In the interest of the patient, if medicinal and painless treatment will accomplish all, or even more, than can be obtained by the use of the knife, it would seem that a majority of the profession would be glad to know of it and would adopt the treatment. 34 Read before the American Medical Assoc., 1888. Fibroma. 48 James J. Terhune, M. D., Brooklyn, N. Y., published notes of four cases of uterine fibroids treated with perfect success. He reports : - 22" The first examination was made by myself and E. S. Bunker, M. D., late Prof, of Obstetrics, Tong Island College Hospital, in consultation ; diagnosis was plain, subserous fibroid tumor (multiple). We prescribed Gardner's Syrup of Hydriodic Acid, teaspoonful three times a day, and were very much grati- fied with the results, which were far beyond our expectations. The patient has fully recovered her usual health and strength and has had no recurrence of the pains or other bad symptoms which she formerly had, and has remained so for a period of fully five years. The treatment is not expected to remove the tumors, but to shrink them up, and thus render them inert. Case 2, over 40 years of age, had been troubled with extreme flowing which greatly emaciated her. At last taken to bed with severe pains and floodings. Examination revealed multiple sub- serous fibroid tumors, two of which were as large as an orange. Tamponed her, relieved the pain by opiates, and put her on Syrup of Hydriodic Acid. The result of treatment was fully as beneficial as case 1. Case 3, aged 41, condition similar to case 2. There were three or four tumors in this case, two of them anteriorly, which were large, pressed forcibly upon the bladder, produced pain in the bladder and some cystitis. This patient was also examined by Dr. Bunker in consultation with me, and the results in cases One and Three, were also verified by him. Under the treatment by Syrup Hydriodic Acid the woman has been brought to a perfectly comfortable condition. She had but one relapse, about two years after the first treatment, due to extra work and fatigue consequent upon removing into a newly purchased house. For a year or more, previous to treatment, she was unable to go out or exercise at all, and after three weeks' treatment was able to go about as she pleased. Case 4. Came to my office very anaemic, had been under the care of physicians two years, more than half the time flood- 32 New England Med. Monthly, Dec., 1894. Goitre. 49 ing more or less. Examination revealed the uterus firmly fixed by sub-serous fibroid multiple tumors ; also protruding from the os was a sub-mucous fibroid with quite large base ; painted the same with Tinct. Iodine Co., and placed her upon Syrup Hydri- odic Acid, with opiates to relieve pain. In two weeks, she stated flooding had ceased and felt better than she had for two years. Her next two monthly periods were five weeks a part, with but three days' flowing. Still under treatment, tumors diminishing in size, with the sub-mucous one becoming more protruding and pedunculated." M. K. Kreider, M. D., Goshen, Ind., reports: "I used Gardner's Syrup of Hydriodic Acid two years ago for a uterine fibroid ; it arrested the growth of the tumor, and it has been gradually growing smaller ever since. I used three or four pint bottles." H. F. Stowell, M. D., Rochester, N. Y., reports: ''A fibroid tumor in the region of the parotid gland, of twenty years' dura- tion. Gardner's Syrup of Hydriodic Acid was used in the case. There was a perceptible shrinkage during the first two months of treatment, after which it remained stationary. There was, however, total relief of various unpleasant sensations in the growth, which sometimes amounted to pain." Jas. A. Williams, M. D., New York City, reports : " Mrs. Geo. M., aged 40, consulted me relative to a fibroid tumor of the breast, about the size of an orange. It was growing and be- coming quite painful. I put her upon Gardner's Syrup of Hy- driodic Acid and local applications of tinct. Iodine. I soon found the tumor being absorbed, and she growing fat. After three months' treatment she returned to her home in Connecti- cut, having gained twenty-five pounds, with scarcely a trace of the tumor." Exophthalmic Goitre. Gardner's Syrup of Hydriodic Acid stands at the head of remedies for this affection, and cases are constantly being re- ported of cures of the worst cases. Goitre. 50 Allen McLane Hamilton, M. D., New York,23 says he relies almost entirely upon Gardner's Syrup of Hydriodic Acid in these cases and has cured cases which were advanced and serious. Drs. J. B. Carver,86 W. B. Fletcher, W. Gill Wylie,24 A. H. Boler,27 J. M. Keller,20 and others have reported numerous cases cured by Gardner's Syrup. Milton P. Creel, M. D., Central City, Ky., reports:28 " With Syrup of Hydriodic Acid (Gardner's) I have treated ten cases of exophthalmic goitre with eight complete recoveries. One case failed to respond to any treatment-the other went away after taking treatment for a month, and I did not see her again." C. F. Mitchell, M. D., C. M., Cleveland, Ohio, reports the following case : " Miss W. E., age 15 ; attending school. Family history in- dicated Scrofulosis. Menstruation regular, commencing when 12 years old. Consulted relative to an enlarged tumor upon her neck. Examination revealed a Hypertrophic Goitre of Paren- chymatous character. The swelling involved both lobes of the Thyroid gland. The patient complained of no pain or difficulty during respiration or deglutition. I immediately placed her upon Syrup Hydriodic Acid (Gardner), in teaspoonful doses, t. i d. ; I applied Galvanism and Iodine twice a week to the tu- mor, and at the expiration of the second week's treatment, mani- festations of softening were present. I then used Galvanism with- out the Iodine at the same intervals and prescribed Bin-Iodide of Mercury ointment to apply night and morning when at home. Regulated her bowels with a tablet triturate, consisting of Calomel, Sodii Bicarbonate and Ipecac. At the expiration of one month's treatment symptoms of lodism appeared ; I then decreased the dose of Syrup Hydriodic Acid to one-half teaspoonful and com- 23 Reference Handbook of the Medical Sciences, page 765. 24 N. Y. Med. Record, May 10th, 1879. 25 Kansas Medical Catalogue, Oct.', 1890. 26 I. N. Love, M. D., in the Medical Mirror, May, 1891. 27 Chicago Medical Recorder, Aug., 1898. 28 Medical Mirror, Dec., 1899. Glandular Diseases. 51 bined it with one minim doses of Fowler's Solution ; she bore this dose very nicely for about two weeks, when symptoms of lodism again appeared, after which I continued the Syrup Hy- driodic Acid in 15 minim doses, and for the Fowler's Solution I substituted a tablet triturate containing Calcium Sulphide, grain 1-8 ; Arsenic Sulphide, grain 1-100, administered two hours after meals; this latter treatment I continued for about three weeks, when the tumor noticeably began to decrease and the in- tegument over it became loose ; finally, my patient told me that she would have to leave the city shortly with her married sister, to reside permanently in another part of the State. I examined the Goitre prior to her departure, and found it had decreased fifty per cent, in size. I gave her a prescription for Syrup Hy- driodic Acid, explaining its merits and action, and also another prescription for Bin-Iodide ointment, and a tablet triturate, con- taining Calomel, Sodii Bicarbonate and Ipecac, to be taken when necessary to regulate the bowels. Recently I interviewed her brother-in-law, who stated that she had complied with my in- structions relative to the administration of medicines, and that the tumor had subsided so that it was hardly noticeable.'' S. A. Oren, M. D., Davis, Ills., April 21st, 1902, says: "Gardner's Syr. Hydriodic Acid has given perfect satisfaction in a case of Goitre on which I used it. The results were very gratifying.'' Glandular Diseases. J. V. Shoemaker, A. M., M. D., Philadelphia, says:29- "Scrofulous persons (those predisposed to glandular troubles) receive decided benefit from its use. The red-eyed children, those having recurrent granular lids with repeated attacks of mild conjunctivitis, derive great relief from Syrup of Hydriodic Acid. For years this agent was officinal, but it was dropped be- cause of its unstable character, which made it not only unpleas ant, but unsafe to administer. In 1878 Mr. R. W. Gardner, of New York, introduced this agent in the form of a Syrup. Suffi- 29 Medical Bulletin, Aug., 1899. Glandular Diseases. cient time has now elapsed to demonstrate that tne claims made for the Syrup are well founded, and that it replaces the salts of sodium and potassium in an entirely satisfactory manner. An important addition in the form of Syrup of Hydriodic Acid has therefore been made to current therapeutics. By the use of this Syrup we obtain in a palatable form, Iodine in its most effective state. Its effect upon mucous surfaces is more marked than with other forms of Iodine, while it is effective in smaller relative pro- portions, and when required, it is so free from irritant action that it may be given to the youngest infant. ' ' A. Dietrich, M. D., Frontenac, Kas., writes under date De- cember 9, 1897, as follows : " I had an opportunity to prescribe your Syrup of Hydri- odic Acid in a severe case of hepatic cirrhosis. Though the gastric disturbance generally attending the malady was very great up to that time, the remedy was surprisingly well retained and its beneficial effect became manifest in a few days. I am more than pleased with its action in this case and shall prescribe it whenever indicated." James E. Clawson, M. D., Philadelphia, Pa., March 21st, 1901, reports: " I have used Gardner's Syrup of Hydriodic Acid with great satisfaction to my patient as well as myself in a case of long standing Enlarged Cervical Glands. I have also used it in other cases with much benefit." 52 Locomotor Ataxia. Henry Chandlee, M. D., Baltimore, Md., reports:36 ' ' The possibility of relief from this dreaded disease when taken in hand early and in which there is probable specific cause, is well illustrated by the following case : Mr. G., aged 41, applied to the Nervous Clinic of the Southern Homoeopathic Dispensary early in June, 1898. Eigh- teen years before, he had contracted syphilis, the case apparently 35 American Medical Monthly, Jan., 1899- L,ocomotor Ataxia. 53 yielding readily to treatment, and since then he had had no fur- ther specific symptoms until the beginning of the present trouble, about eight months ago. The condition was as follows : Loss of tendon reflex in both legs, fugitive pains in legs and back, irregular gait, feeling in feet as if walking on balls, loss of appetite (possibly from medicine taken). Nux vomica in the course of a few weeks produced some alleviation of the pains and a decided improvement in the gastric symptoms. At this time it was decided to try the effect of iodine because of the specific history, and as iodide of potash had been largely used, Gardner's Syrup of Hydriodic Acid was determined upon, because of its well known purity and stableness of compo- sition. The results have exceeded all expectation. Within three weeks there was almost entire cessation of the pain and sensa- tions in the feet. At the end of another month the ataxic symp- toms were decidedly improving. In September there was some return of the patella reflex ; and at this writing, December, it would take a close observer to recognize ' locomotor ataxia ' symptoms as being present. ' ' PAGES 55-60 MISSING PART II PHOSPHORUS AND THE HYPOPHOSPHITES The Assimilation of Phosphorus Single Chemically Pure Hypophosphite Salts in Phthisis and other diseases Theory of their action and Clinical Data INTRODUCTION. To John Francis Churchill, M. D.,* formerly of Paris and now of London, is the world indebted, for, we may say, nearly everything of a scientific nature that is known regarding the hypo- phosphite salts as medicines. He was the first to test them in treatment, and he has given the world in his many scientific works,f a comprehensive, logical and scientific theory of their action, not only in Phthisis, but in all their valuable applications. He arrived at the conclusion that the Hypophosphites were the proper remedies for Phthisis by hypothetic induction, which has been verified by clinical experiment, and confirmed by the concordance of a wide and numerous array of facts. A profound pathologist, he was the first to observe that phthisis was the result of a deficient supply of a necessary bio- logical element which controls oxygenation in the organism. His first experiments^ were conducted from 1852 to 1855, ♦John Francis Churchill, M. D., Paris, 1848; M. D. St., And., 1857; B. 6s Lett., Paris 18375 B. 6s Sc., Paris, 1838; Corr. Mem. Soc. Roy. des Sci. M6d. de Bruxelles; Ex-Vice-Pres. Paris Med. Soc., Etc. +" Du Moyen de Pr6venir la Phthisie par 1' emploi des Hypophosphites, Paris, 1859." " On the Prevention of Consumption by the use of the Hypophosphite, London, 1859." " De la Cause Imm6diate de la Phthisie Pulmonaire et des Maladies Tuberculeuses, et de leur Traitement specifique par les Hypophosphites, Paris, 1864." " Recueil d'Observations, Memoires, Rapports et Documents sur le Traitement des Mal- adies de Poitrine au moyen des Hypophosphite, Paris, 1873." " Consumption and Tuberculosis. Their Proximate Causeand Specific Treatment by the Hypophosphites. London, 1875." " Letters to a Patient, London, 1888." " On the Increase of Cancer in England," London, 1888. t For particulars, see "Historical sketch of the First Use of Hypophosphites in Medi- cine," by R. W. Gardner. Introduction. 64 while he was practicing medicine in Havana, Cuba. His sub- sequent researches have been carried on in Paris and London, where he established public dispensaries, especially for the treat- ment of this disease, and maintained them at his own expense. His experience of over half a century in this specialty, dur- ing which period he has treated successfully thousands of cases in all stages of the disease, has demonstrated the truth of his theory. No other treatment has ever shown one-tenth of the re- coveries which have been attained by him. It is very remarkable that facts like these should be so large- ly ignored by the medical profession. Substantiation of his statements is complete. Every medical man may duplicate his results if they will but follow his scientific methods accurately and in detail. It is pitiable to think of the vast numbers of our fellow be- ings who are daily dying of this disease, whose lives might be saved, if the profession more generally understood and adopted his suggestions. PHOSPHORUS. Phosphorus was discovered by Brandt in 1669. It is never found in nature in a free state. It is mostly prepared from bones (calcium phosphate) by reduction. It is largely distrib- uted in natural products, principally as phosphate. The fertil- izer (" phosphate rock ") which is largely calcium phosphate, combined with iron, alumina, fluorine, etc., is an example. It is found also in smaller proportion in vegetable life. While in the elementary state, its affinity for oxygen is enormous. It is necessary to keep it out of contact with air, under water, or it will spontaneously inflame at a temperature above 500. A rational understanding of these properties should forbid its use, in this state, for internal medication, as its destructive action upon the delicate mucous membranes of the stomach are serious and inevitable, if its use is persisted in. The action of phosphorus upon the system is to stimulate the nervous function by supplying its natural motive power-the fuel which nature requires to feed nervous energy ; to increase functional action generally, assimilation of food, haematosis, oxy- genation, metabolism and elimination. But these objects are not attained advantageously, or safely, by the use of the element phosphorus itself, because its oxidation in the stomach is so violent as to cause damage to the mucous tissues, and so much irritation and consequent inflammation that serious consequences ensue. Not only this, the oxidation of this element in the first stage sets free phospho retted hydrogen, an active poison, which being soluble, is taken up by the stomach secretions and absorbed ; this is the active agent which causes necrosis in cases of poisoning by Free Phosphorus. phosphorus. Match-makers and workers in phosphorus suffer from this cause. Phosphoretted hydrogen is, however, given off only dur- ing the first degree of oxidation ; subsequent oxidation is free from objection on this score and is also free from all irritating effect. That portion of the phosphorus not changed into phosphor- etted hydrogen combines with oxygen obtained from the tissues by violent chemical action, until after the first atom has com- bined; it then unites with the aqueous secretions, being now for the first time soluble, and forms hypophosphorous acid (HPH2O2) ; this, of course unites with whatever base may be present, and a hypophosphite is the result. All solutions of phosphorus when administered internally, are changed in the stomach, the phosphorus being precipitated in a solid form by the aqueous secretions, as water invariably precipitates phosphorus from all its solutions. Endosmosis cannot take place with a solid substance. Thus the effect of the administration of free phosphorus is to form a solution of phosphoretted hydrogen, which produces toxic effects-and a solution of a hypophosphite. In the mean- time great damage is done the organism by making the stomach the laboratory for the preparation of a hypophosphite, causing de- struction of tissue and great irritation. It is evident that it is better to administer the already formed hypophosphite. The amount of phosphorus which can be tolerated, produces an in- finitesimal amount of Hypophosphite. 66 HYPOPHOSPHITES. Considering the amount of research in other directions, it is a remarkable fact that the subject of Hypophosphites should have remained so little investigated from a strictly scientific standpoint. The probable reason for this lies in the fact that, at first, the only preparations of them brought to the attention of the profession in this country, were complex combinations of impure salts, and the explanations * accompanying such Hypophosphites. 67 preparations were mis-statements of their scientific applica- tion, and frequently, purposely altered quotations from Dr. Churchill's works, the object obviously being to make certain manufacturers' combinations fit the requirements of all cases in which any particular hypophosphite might be indicated. This empirical method of using these very valuable salts, precluded that attention to the study of the therapeutic applica- tion of each salt by itself, which is necessary to a proper com- prehension of the scientific application of each. In fact, results attained by these complex combinations, could never, in the nature of things, be traced to their cause. The only method by which medicine, in its application to disease, can be intelligently studied, is by observing the effects upon the organism of each particular agent by itself. By combi- nations of several, results are so clouded as to be of little service in establishing scientific data upon which an intelligent theory of therapeutic action can be formulated. Thus, owing to this misleading literature, not only impure Hypophosphites, but irrational combinations of them have been constantly prescribed by the profession. These combinations have resulted in antagonistic effects, due to the varied action of the different bases, and this has, to a large extent, prevented the favorable results which distinguish the use of the single hypophosphite, when prescribed according to proper indications, and used in a pure state, protected from oxidation by sugar, as recommended by Churchill, the first authority to apply them in medicine. Text-books upon therapeutics have almost entirely ignored the use of hypophosphites as single remedies, each applied to its peculiar indications. The disadvantage of combinations will be more clearly seen, if we consider the diverse applications of other salts of a single acid. Take, for instance, the Chlorides of Ammonium, Iron, Sodium, Zinc, etc. Would it not be considered absurd to com- bine all of these in a single preparation, and expect any satisfac- tory or intelligent results ? In this view of the case, is it not re- Phosphorus Assimilation. markable, that ever since the hypophosphites have been used in medicine, they have, at least in this country, almost wholly been prescribed in this irrational and unscientific manner? In lectures upon therapeutics at the medical schools, the use of these unscientific combinations has been perpetuated ; as little or no attention has been given to the individual indications of the separate hypophosphite salts. The main object in view, in the administration of a hypo- phosphite, is the exhibition of phosphorus in a non-irritant and oxidizable form. This object can be attained just as perfectly by the administration of a single hypophosphite as by a combina- tion of several, because the dose of the combination contains no more phosphorus than the dose of a single salt. The bases, lime, soda, iron, manganese, potassium, etc., fulfill cer- tain secondary indications, and these indications differ with each base. Medicine should never be given recklessly, with no rational object in view. The therapeutic action of these various bases differ so widely, that instances are rare where more than two are indicated in combination. If the different bases are not indicated, they are productive of evil, because all medication produces some change in the organism ; if this is an unfavorable one, the pa- tient is better off without it, as it adds to the already existing complication of abnormal conditions. 68 PHTHISIS. All scientific and successful practitioners admit that in the study of disease with a view to treatment, it is necessary as a first measure to ascertain without doubt, if that be possible, its primary cause. In cases of scarlet fever, measles, diphtheria and other directly contagious or infectious diseases, whose attacks are irrespective of vital conditions, with a certain number of days intervening between exposure and the first invasion (the in- cubative period) there can be no doubt that a certain morbific principle is the cause, as the period of incubation has been es- Etiology of Phthisis. tablished and demonstrated by observation of innumerable in- stances. Phthisis has been classed as an infectious disease by many physicians, based upon the discovery by Koch of the tubercle bacillus. This microbe, having been discovered in the sputum and portions of the organism of phthisical patients, has been largely believed to be the primary cause of the disease. Upon this supposition the treatment has been modified with a view to lessen or if possible to exterminate this germ. This has led to the use of antiseptics and germicides, the action of which has resulted in disturbance of digestion and appetite, gastric irritation, and lowered vitality. If it were an absolutely established and demonstrated fact that the tubercle bacillus is the primary cause of the condition, this treatment would be the only logical course indicated. « But it is well known that there is, in all these cases, a period in the initiation of the disease, called the " pre-tubercular " stage, during which the tubercle bacilli are not present. The origin of the disease ante-dates the invasion of the tubercle bacilli by quite a long period, often many months. It is also observed that there is a breaking down of cells and that a degenerative action due to a depraved condition of the tis- sues has supervened prior to such invasion. The inference then seems plain, that the tubercle bacilli be- long to a class of putrifactive germs which immediately infest decaying animal matter, but cannot live in normal tissues. As thousands of persons are exposed to the danger of infec- tion by the tubercle bacillus, which is known to exist in innu- merable numbers in populous districts everywhere, why do not all contract the disease ? The fact that so many physicians and nurses, who are in constant contact with patients suffering with this disease, do not contract it, is a strong argument against the specific infective character of the microbe. It is now acknowledged that patients improve when, with 69 Etiology of Phthisis. proper precautions, they are induced to live out of doors to a considerable extent. In like manner those not affected with this disease are in- vigorated and vitalized by out of door life. This shows the antagonism between vitality and phthisis and is another proof that could the patient retain his normal strength and vigor he would be immune against the disease. It is always unwise to accept and act upon any hypothesis, particularly in the treatment of disease, until it has been abso- lutely proven to be correct by corroborative scientific evidence. The Hypophosphites have been long acknowledged to exert a favorable action in the treatment of Phthisis. Under their use the tubercle bacilli decrease in number. They are known to increase metabolic action, to stimulate haematosis, to cause increased alvine discharges, to increase ner- vous energy, and previous to the discovery of the tubercle bacil- lus were considered to be the best measure for treatment. But in the treatment, the conservation of energy by itself, is not all that is imperative. There is a cause for the condition, and until this cause can be demonstrated and corroborated, all treatment must be obscure. In 1855, Dr. J. F. Churchill started certain investigations as to the etiology of Phthisis, the result of which convinced him that the disease was caused by a lack of oxygen in the tissues. His subsequent researches, his extraordinary experience in the treatment of the disease and the corroborative physiological and pathological observations which he has chronicled, are of such a scientific character as to carry conviction to all thoughtful, receptive investigators, who are not prejudged.36 The writer is aware that very many of the profession are so convinced of the truth of the bacilli theory, that they will not consider or even read any matter which attributes the cause of the disease to any other source. Dr. Churchill was the first to use hypophosphites in medicine. He was led to their use in phthisis, upon the supposition 70 •« See " Historical Sketch of First use of Hypophosphites in Medicine."-Gardner. Oxidizable Phosphorus. that phosphorus existed in the organism as a biological element, in a lower degree of oxidation than the phosphate. That this form of phosphorus acted, by its chemical affinity, as an initia- tory agent in attracting and utilizing the inspired oxygen. That when this form of phosphorus, which he called the phosphide ele- ment, was deficient in quantity, from oxidation into phosphate or from a lessened supply from natural sources, the degree of oxi- dation of the tissues was less than the normal. That this phos- phide element is not only essential for the oxidation of the tis- sues, but also is the source of energy of the nervous system. By supplying an oxidizable element to the tissues, it inau- gurates, promotes and increases metabolic action, which is life. The devitalization, nervous depravity, emaciation and defective nutrition observed in the disease, are due to insufficient supply of this element, which is biologically necessary for oxygen sup- ply. This phosphide element (oxidizable phosphorus) must not be confounded with the phosphate ; phosphates are burned out ashes, so to speak, in which the phosphorus has already com- bined with oxygen to saturation ; it is therefore useless as a means of promoting metabolism, as the compound leaves the body, as it enters it, without change ; it is a component of fully developed, and consequently, stationary histological elements, and is taken as such into the system, like other permanent salts, such as the carbonates, chlorides, etc. The phosphorus in the Hypophosphite is combined with one atom of oxygen only, while the phosphate has already combined with four atoms ; so that in the phosphate the whole of the phos- phorus is already oxidized, while in the Hypophosphite three- fourths of the phosphorus is still in a combustible or oxidizable condition. The phosphate, which is always furnished by the food in sufficient if not excessive quantity, has no influence whatever upon the disease, being constantly excreted as a waste product. Treatment by phosphates has been tested thoroughly by compe- tent observers with nothing but negative results. 71 Tissue Oxidation. 72 The phosphztZ? element, on the other hand, exists in larger proportion in the gray matter of the brain than in any other part of the organism. It is present in all the normal tissues of the body. Intra-organic Oxidation Essential to Life.-The impor- tance of oxygen to the tissues is admirably illustrated in the almost instantaneous regeneration produced in the sloughing ulcer or cold abscess when peroxide of hydrogen is brought in contact with it; the pus and putrid matter disappear as if by magic, and the surrounding tissues are so stimulated that if brought into contact and antiseptically dressed, the parts will heal as if by first intention. This wonderful local effect is but an expression of the great need of the entire organism for this element. The efficacy of chlorate and permanganate of potassium, both powerful oxidizing agents in putrifactive and germ diseases, like scarlet fever, diphtheria, etc., is thus explained. Septic matter, and the germs which accompany it, are de- stroyed when oxygen, in the nascent state, has full play ; this is what keeps our bodies in an aseptic condition during life, and the lack of it is the cause of putrifaction after death ; it is the sustainer and supporter of life, a necessity to animal existence. We know the carcass of a slaughtered animal shortly under- goes putrifaction, and its incidental accompaniment, spores and microbes appear. Why ? Because the circulation being cut off the tissue no longer gets its supply of this necessary element, brought from the lungs and distributed through the organism ; the blood, a fluid tissue, becomes pathologic, infective germs may then find in it a nidus for their development, while normal blood is a germicide. If it be true that oxygen is a destroyer of septic material, its presence in normal quantity in the organism would also pre- vent the formation of such material, and keep the tissues free, not only from septic matter, but also from those germs which find their habitat in, and depend upon, diseased pabulum for their existence. Intra Organic Combustion. 73 It is stated that the proportion of carbon di-oxide excreted at each expiration is from 3 to 6 per cent., depending upon the length of time the air is retained in the lungs. The elimination of this waste product, after inspiration of atmospheric oxygen, reminds one forcibly of the same reaction occurring when the solution of peroxide of hydrogen is applied to the sloughing ulcer, when, as physicians all know, there is an effervescence of carbon di-oxide, resulting from the combustion of putrid matter, leaving only water and clean tissues, the extra atom of oxygen having been expended in the reaction. The atmospheric oxygen, in like manner, after being con- veyed by the respiratory process into the animal tissues, acts upon the proximate principles therein contained, goes through a certain number of combinations and is finally expelled as carbon di-oxide. " That there is a direct connection between the excretion of the phosphates and waste of nervous element, is proved by the fact that this excretion falls to its lowest point during the cessa- tion of nervous activity ; and that in the insane the excretion of the phosphates is considerably increased during paroxysms of ex- citement, while on the contrary it falls below par during the sub- sequent period of exhaustion." " The consequences of the phenomenon or feeling of exhaus- tion do not, however, stop at the waste of the immediate available phosphide element contained in the nervous system. As this ele- ment exists in the albuminoid principles which constitute the bio- plasm or histogenic stock from which all the organs and tissues of the system are formed ; as there must be a balance between the proportions of this element contained in the different parts of the system, we have a right to infer that its decrease in one part must, after a certain time, produce a corresponding diminution in the rest; and, as we have found that the phosphide element is probably the exciting and initiatory agent of intra-organic molec- ular combustion, whatever produces a waste of the oxidizable phosphorus in the system must diminish general molecular oxida- tion and the amount of excreted carbon dioxide." Phospholigy. 74 "Every kind of activity, whether intellectual, emotional, lo- comotory, or sensual, is therefore conditioned, either directly or in- directly, by a wear of the phosphide element, as shown by the excretion of the phosphates, and whenever this activity exceeds a certain limit the organism is no longer in a normal state."- Churchill. It will thus be seen what an important part oxidizable phos- phorus takes in the system by seizing and storing oxygen for eco- nomic use ; but its utility does not stop here ; it is a direct stim- ulant and tonic to the nervous system, irrespective of its use in attracting oxygen ; the fact that it is found in largest proportion in the gray matter of the brain, the throne of nervous power, would of itself be sufficient reason for the belief that it is an element of vital necessity. It can hardly be looked upon in any other light than as a necessary food supply, for it is an element in various foods of animal origin. It is particularly present in milk, that remarkable secretion upon which infant life is almost exclusively dependent during its earliest period, and during which time there is wonderful pro- gress in development, and the greatest need for all elements nec- essary to sustain rapid growth. It has often been noticed, as a peculiar feature of phthisis, that the venous blood is much redder than the normal. This condition is directly traceable to " Phosplioligy " (from Phosphorus, and o2rpoc=Scanty). The red color of normal arterial blood is due to oxy-haemo- globin ; in phthisical patients the cells have partially lost their power of chemical attraction for oxygen, in consequence of a de- ficient supply of the phosphide principle ; the result is deficient metabolism, the cells failing to absorb the normal proportion of oxygen from the haemoglobin ; the latter is thus returned through the venous system as oxy-haemoglobin instead of reduced haemo- globin, not having accomplished its mission. Upon the administration of a hypophosphite, the color of the venous blood is very shortly changed to the normal, or even Color of the Blood. darker, showing that the tissues, by their increased affinity, have been enabled to take up the oxygen from the oxy-haemoglobin, which results in the restoration of the normal color to the venous blood. This phenomenon also furnishes a remarkable object lesson, demonstrating the power of the hypophosphite to initiate and stimulate metabolism. 75 THE INFLUENCE OF MOLECULAR ACTIVITY UPON TUBERCU- LIZATION. " Phospholigy lowers the rate of general oxidation, and thus also the activity of all molecular changes. ' ' If the formation of tubercular matter is caused by the organic material becoming so imperfectly oxidized as to be unable to con- tinue its office in the system or to be excreted, it follows that the greater the activity of assimilation, the greater the amount of new tissue in process of formation, and the more general the formation of new tissue is throughout the system, so also the more rapid will be, in cases of phospholigy, the production of tubercular matter, and the more generally will it be disseminated throughout the system. ' ' This accounts for the very remarkable fact, that tuberculiza- tion is much more rapid, and that tubercular matter is much more generally disseminated throughout the system in children than in adults, and in adults than in the aged. " In children, as is well known, the lung is far from being so frequently the exclusive seat of tubercle as in adults, both the intestines and the brain being frequently involved in the disease. " But in children, increased molecular activity will, as we have seen, be particularly powerful to produce tuberculization, be- cause, as already said, with them the phosphide principle is less in quantity than in after life. So that not only do we see why children are more prone to tuberculosis, but also why they are more liable to tuberculization. " The fact that increased vital activity and the formation of Color of the Blood. 76 new tissue predispose to tuberculization also explains why it is more likely to occur in the course of or during convalescence after states or diseases attended by exhaustion, such as fever, suppuration, lactation, etc.; during all of which there is an in- creased or abnormal activity of the organism. " It is in these variations of molecular change, that we must look for an explanation of the antagonism between the tubercular condition, and a series of complaints characterized by cyanosis, or cyansemia, that is, an increase of the venous condition of the blood. This is the case in advanced age, when we know tuber- cular disease is less frequent and more capable of arrest or of spontaneous cure. We meet with it also in drunkards, in patients with hypertrophy of the heart, in those in whom the foramen ovale remains open, in aneurism of the aorta, in diseases which increase the capacity of the chest, such as vertebral incurvation, or tumors of the abdomen, also in asthma and emphysema. " Now all these morbid conditions have one common charac- teristic, a decrease of the arterializatiou of the blood, owing to a diminution of the oxygen introduced into the system, and in all these morbid states there is marked influence antagonistic to the progress or the development of tubercle. ' ' Here we come upon a series of facts showing that the intro- duction into the system of a smaller amount of oxygen is antag- onistic to phthisis. "This seems a strong objection, but upon examination it will be found that these very facts fit into and confirm the theory. "The dark or cyanotic condition is an index, not of incom- plete, but of very complete oxidation, as it is characteristic of venous blood, that is, when the oxygen of the arterial blood has been taken up by the tissues. ' ' The red color of venous blood in tuberculosis is a proof of the incomplete combustion of the oxidizable material; when a gland or muscle is at rest the return blood from .it is red, like arterial blood, while if they are in a state of activity or contrac- tion, that is, while oxidation is taking place, the return fluid as- sumes the dark color of venous blood. Degree of Oxidation. 77 1 ' But this dark color of venous blood not only represents com- pleteness of combustion, but where this color is found there is a co-existence antagonistic to tuberculization, especially a notable retardment of the circulation of the blood. "If in these cases the lungs absorb less oxygen, and excrete less carbon-dioxide, it is not because the blood which is carried back to them from the system is deficient in carbon-dioxide, as is the case in tuberculosis, but because, pulmonary circulation being hampered, the oxidizable material brought in contact with the oxygen absorbed by the blood is less in quantity than in the normal state. " This is proved by the slowness of organic metamorphosis, and of all the vital actions, in the different morbid states which have just been enumerated. Hence it follows, that though the total amount of oxidation and of carbon-dioxide produced is di- minished, the degree of oxidation of the combustible material is complete, or may even be raised, because the quantity of blood coming into the lung is lessened, and because, owing to the slow- ness of the circulation, it is kept longer in contact with the oxygen. " A scientific result when once verified and confirmed by a sufficient amount of independent testimony cannot be invalidated by any number of negative instances, because, although there may be but one way of doing a thing right, there may be a hundred ways of doing it wrong. Negative results, therefore, only show that they have been arrived at under different condi- tions from those which lead to positive results. " Any one who takes the trouble to study the question, will find that there is hardly a single detailed instance of the appa- rent failure of the hypophosphites, that cannot be distinctly traced to neglect or ignorance of some one or more of the con- ditions which have been shown to be necessary for their success- ful use. " A complex process, such as the cure of a case of consump- tion in the second or third stage, requires to be carried out with the same care and the same attention to minute details as an ex- Impurities in Hypophosphites. 78 periment in chemistry or physiology, or an operation in surgery." -Churchill.* WHY PHYSICIANS HAVE NOT BEEN GENERALLY SUCCESSFUL IN THE USE OF HYPOPHOSPHITES IN PHTHISIS. In the first place, the most important of all considerations is the pharmaceutical condition of the remedy. Dr. Churchill has laid down explicit directions in this particular, which must be absolutely observed, or failure will inevitably result. Commercial hypophosphites made into syrups by the apoth- ecary, or the use of these, as found on the market in the saline state, is one of the principal causes of the uniform disappointment met with in the use of these salts. Physicians and apothecaries alike are in the habit of ignor- ing this most important of all considerations. The hypophosphites appear to be peculiar in that their physiological action is much impaired, or wholly prevented, by the presence of impurities. Churchill purposely added a small quantity of an alkaline carbonate to the hypophosphite he was administering to a number of patients who were progressing fav- orably ; immediately, the favorable progress was interrupted and the patients began to lose ground ; upon being again put upon the syrup of the chemically pure salt, the favorable action of the remedy was at once restored. This test was frequently ap- plied with always the same result, thus establishing the fact that a chemically pure salt only should be administered. This evidence has been corroborated by Janson, Maestre, Parrigot, Thorowgood, Fedeli, de Bremon and others. ' ' All physicians who have employed the hypophosphites with success have pointed out the absolute necessity of employ- ing them chemically pure."-London Lancet. This proves how fallacious is the claim of those who openly * " Dr. Churchill is not only a good chemist and an excellent physiologist; he is above all, a practical physician. His clinical facts form a constant series of inductions, in which signs are always referred to their governing conditions, and results are made to constitute a science, because they are continually traced back to the causes upon which they depend." -" La France MSdicale." Oxidation of Hypophosphites. advertise as an advantage, that their compounds have an alkaline reaction. All chemically pure hypophosphites have a neutral reaction ; an alkaline reaction shows the presence of a hydrate or carbonate, which, not being a hypophosphite, is manifestly an impurity. Inasmuch as hypophosphites, even when chemically pure, do not remain so when kept in the state of salts, and as aqueous solutions of them are still more prone to oxidation, and conse- quent deterioration, unfitting them for medicinal use, the only reliable form, upon which dependence can be placed for favorable therapeutic action, is that of recently prepared, chemically pure hypophosphites, converted into syrups at once after preparation, to avoid atmospheric oxidation ; they should also be marketed in packages of not over one pint, as the freqent removal of the cork, each time they are used, admits a fresh quantity of air to exert its influence upon the preparation. This is in strong contrast to the usual practice of manufac- turing houses, who put their hypophosphite syrups in from five pint to five gallon containers, as though they were stable com- mercial products, instead of delicate and perishable medicinal preparations. However, in these cases, it probably makes little difference, as their preparations are so impure originally that a little added impurity is not material; and inasmuch as the cost of large containers is relatively less, it is more profitable to them and their customers-the substituting pharmacists. It is generally considered, even by the profession, that all preparations of hypophosphites are equally reliable, and no atten- tion is paid to this point. The hypophosphite salts are rapidly oxidized when kept in this form, as they absorb moisture, and are necessarily exposed to the action of the air. This change occurs more rapidly when the salts are in aqueous solution, unprotected by sugar. Hence such preparations put on the market,and lauded as superior to the Syrups, are therapeutically inferior, and cannot, as Churchill de- clares, be depended upon for satisfactory effects. Great stress is laid upon the fact that such preparations do not cloy the stom- 79 Polypharmic Combinations. 80 ach, but Syrup, if diluted sufficiently when taken, or if mixed with a little lemon juice, or given in milk or coffee, can always be retained without repugnance. Preparations of Hypophosphites containing wine are contra-indicated in phthisis, as stimulants prevent the oxidation which the Hypophosphites are given to effect. The Elixirs prepared by the writer, containing wine, and less sugar than the Syrups, have proven that this form is objectionable ; conse- quently we have informed the profession of this fact, and have discouraged their use for some years. When it is considered that the constitutional action of the remedy and its effectiveness is the object of its administration, the importance of exhibiting it in the most perfect form will be self evident.* In the next place, the hypophosphites are given in poly- pharmic combinations, which, in the light of a scientific knowl- edge of the therapeutic properties of each, and a consideration of the varying symptomatic conditions of each patient, as well as the modifications wrought by the remedy, is fatal to any success- ful result, as any physician with a proper knowledge of the sub- ject must admit. Dosage. (In Phthisis). In the administration of Hypo- phosphites this subject is of essential import. In Phthisis, the quantity administered must be adjusted to the physiological tol- erance of the patient ; over-dosing by these remedies is sure to produce disastrous consequences if continued. The chief danger in such cases is that of a too rapid increase of the function of haematosis. While the remedy is given expressly to increase this function, such increase must not be pushed faster than the patient can safely bear, otherwise softening and sloughing of the tubercular matter, and haemorrhage will result. There must be no sudden spurt or burst and no one function can be stimulated •After over twenty-six years of experience in preparing these Syrups in strict accord with Churchill's views, and a close study of his recommendations as to the essential , har- maceutic conditions necessary for success, together with the actual practical results at- tained by thousands of the most careful and eminent clinicians, it is acknowledged by all who have used them that Gardner's Syrups are unequalled by any other preparations of hy- pophosphites on the market. 81 Treating Symptoms. physiologically and usefully to the patient, unless the others are able to follow and keep up with it. " Health is nothing but the equilibrium of all the functions of the system.37" The doses administered in Phthisis are almost invariably too large, as many are not aware that hypophosphites are capable of producing evil consequences when given too freely ; the relapse or haemorrhage, or sloughing of the tubercular deposit which nec- essarily follows, and which is a direct result of over-dosing, is attributed to the inevitable evolution and progress of the disease. Instead of concentrating the mind upon the real cause of the condition and keeping it continually before them, viz., that it is an insufficient oxidation of the tissues, and that the object of treatment is to restore the normal degree of combustion, which, when accomplished, entirely eradicates the diathetic state upon which the local lesions depend, removes and destroys the tuber- cle bacilli, whose existence depends absolutely upon a de-oxidized state of these tissues, the physician is continually treating local "symptoms, by various remedies which are therapeutically contra- indicated by the constitutional state. This results in complications which had no previous exist- ence, and only increases and multiplies the problems to be solved in treatment. Anodynes, narcotics, sedatives, and other medication, given to modify symptoms, while the hypophosphite is also being ad- ministered, simply prevent the desired effect of the latter, and nullify the treatment. Stimulants prevent the favorable effects of the hypophosphite. " During the summer season, when most of the symptoms in phthisis, and particularly the cough, are frequently reduced, or even disappear for a time, the hypophosphite treatment should not be left off, as is too frequently done. On the contrary, as the disease is then reduced, so to speak, to its simplest expres- sion, this is the very time for using the remedy, as the patient is in the best condition for it to produce its full effect."-Churchill. 37 Consumption and the Hypophosphites.-Churchill. Physiologic Effects. 82 " First, or crude stage.-Characterized by a modification of the percussion or auscultatory sounds, without the production of any abnormal signs. Second, or period of softening.-By the presence of abnor- mal crepitus, in lieu of the physiological respiratory murmur. Third, or period of excavation.-By the existence of cavern- ous rales and sounds. ' ' CLASSIFICATION OF PHTHISIS BY STAGES. GRADUATED SCALE OF LESIONS. " First.-The diathesis with little or no deposit. Second.-Confirmed deposit confined to a portion of one lung, and in the first stage. Third.-Deposit in the second stage in one lung. Fourth.-Deposit in the first stage in both lungs. Fifth.-Deposit in the first stage in one lung, and in the sec- ond in the other. Sixth.-Deposit in the second stage in both lungs. Seventh.-The third stage ; excavation, with only one lung affected. Eighth.-Both lungs affected; one in the third, the other only in the first stage. Ninth.-One lung in the third stage, one in the second. Tenth.-The third stage in both lungs. Eleventh.-Complications,such asdiarrhoea, laryngitis, etc." PHYSIOLOGIC EFFECTS OF THE HYPOPHOSPHITES. " Nervous Energy.-One of the first effects produced by the Hypophosphite is a general increase in nervous energy, with an unusual feeling of ease and comfort. " Appetite.-The second effect is an increase of appetite, which sometimes becomes enormous; as a natural consequence of this fact, digestion is much improved, and the bowels also become more regular in their action. " Haematosis.-The above phenomena are soon followed by increased activity of hsematosis; * * * both the quantity and color of the blood are so rapidly increased that the Hypo- Pathologic Effects. phosphites are undoubtedly the most powerful haematogens hitherto known. " Venous Plethora.-After a time, which varies with the constitution of the patient and the doses given, there are evi- dent signs of venous plethora, as shown in the color of the face, the redness of the mucous membrane of the lips and eyes, and the fullness of the superficial veins. ' ' Sometimes this effect is so strongly marked that persons who all their life-time have looked pale and delicate take on the appearance of full and robust health. " When this stage has been fully reached, if blood be with- drawn from the patient, or be lost by accidental haemorrhage, it will be found much darker than the natural state ; so much so that the patient's attention is usually struck with this appear- ance. The same character is observed in the menstruation, which becomes easier, more abundant, and more regular. " Weight.-The patient generally gains in weight. " Growth.-If the subject be young, growth is notably ex- cited, and children while taking a Hypophosphite never show the signs of weakness and emaciation to which they are otherwise prone after too rapid development." 83 PATHOLOGIC EFFECTS. " These include all effects produced by the remedy, different from those which exist in the normal state. As soon as there is any manifestation of a morbid phenomenon, the action must be looked upon as pathologic. ' ' These effects are produced when the hypophosphites have been taken too long, or in too large doses. ' ' Breathing may become short and uneasy ; there are pains in the chest and aggravation of cough and expectoration, and at this period auscultation frequently shows increase of the local signs, consequent upon augmented hyperaemia of the lungs. " If, in spite of these symptoms, the use of the remedy is persevered in, haemorrhage takes place from the respiratory, or even from the digestive mucous membrane. Pathologic Effects. " This generally makes its first appearance in the shape of epistaxis, after which there may be an attack of haemoptysis, perhaps for the first time. " Persons kept in this condition for a time are affected with piles, and those which they formerly had, and which had disap- peared, are reproduced ; this may go to the extent of real intesti- nal haemorrhage. " Most of the symptoms may show themselves from the very beginning of the treatment, if it is begun with too large doses. " They are more easily and rapidly produced in proportion to the youth and sensitiveness of the patient, as in cases of women, children, and people of nervous or sanguine temperament. " Lassitude, Prostration.-When the Hypophosphite has been taken too long, or in too large doses, the first pathologic effects generally show themselves in the nervous system. " Patients, who up to that time had felt a gradual or perma- nent increase of strength, begin to complain of weakness, per- haps of a feeling of lassitude, of vague or wandering pains in the limbs, of somnolence. " Sometimes lassitude may be carried as far as complete pros- tration. "Headache, Giddiness, Fever.-If allowed to proceed, it may be followed by headache or giddiness, disturbance of the eyesight, noises in the ears, and fever may finally supervene. " Indigestion, Loss of Appetite.-Digestive function is equally disturbed; appetite, before increased, may fall away or be lost. " Colic or Diarrhoea.-There may be colic or diarrhoea. All these signs which point to some disturbance of the ner- vous system, seem to be directly connected with an exaggeration of the function of haematosis, and are accompanied or preceded by disturbance of the circulation. Among the different signs of this pathologic condition, two deserve particular attention. " Fulness of the Face ; and Epistaxis. The fulness of the face, as the name indicates, refers to a 84 85 Fulness of the Face. peculiar look of the patient, similar to what may be observed in delicate persons after a hearty meal, or after moderate exercise. There is often a flush on the face ; which to the inexperienced observer resembles that of perfect health; the cheeks are less hollow, sometimes appear quite full, and when this stage has reached its maximum there is a slight swelling or puffiness of the malar region, and the lower eyelid. ' ' This peculiar aspect is not the same as the Icok of hectic fever, the redness of the face is not sharply circumscribed to the cheeks, but spread over the whole face, as in a state of health. " When once carefully observed it is not difficult to recognize again. The slighter the amount of local lesion, the more strongly marked it appears, and the earlier it occurs; sometimes at the end of a few days. " It is more apparent in persons of a lymphatic or sanguine, than those of a bilious or nervous temperament. " This is a sign of great clinical value, for it indicates that the physiologic action of the remedy is near or has already reached its maximum. " It is therefore highly important that it should be recognized in time, as it enables the physician to forsee, and consequently by suspending or decreasing the treatment, to prevent the acci- dents or complications which would not fail to follow if it were injudiciously persevered in. " This fulness of the face marks the limit of physiologic ac- tion. " Epistaxis shows that the patient is entering the sphere of pathologic phenomena. These latter are frequently preceded by this sign, which is, therefore, particularly worthy of atten- tion. • " I have shown the necessity of distinguishing between the physiogenic action of a remedy and its pathogenic manifesta- tions. In like manner it is indispensable that a distinction should be made between its therapeutic effects, and the curative result. " As I have already explained, the therapeutical effects of a Effect of Combinations. medicinal agent are the result, either of its physiogenic or of its pathogenic action ; but they are of a more complex order, while they are less complex than the curative result. " Each step in these different orders of phenomena therefore, requires for its manifestation an increasing number of conditions, because each step in the scale is more complex than the one which precedes it. " The cure will be the final term, the result of the different antecedent modifications produced in the system and can only be arrived at provided they are maintained within certain limits, and kept up for a sufficient length of time. ' ' Effect of Combinations.-The hypophosphite is admin- istered for the purpose of assimilating the electro-positive ele- ment, oxidizable phosphorus. The base or carrier of this element is also of the greatest importance, as it produces its peculiar action upon the organism, and that one only should be administered, the physiological ac- tion of which, is especially fitted to harmonize with and supple- ment the action of the phosphorus element upon the existing condition of the patient at the time of administration. Surely the patient has already enough to battle against, with- out additional unnecessary complications. Now the whole trouble and objection to the use of combina- tions, lies in the effects of the electro-negative elements, which produce secondary and complicating difficulties. Combinations of different hypophosphites with strychnine are productive of gastric troubles, such as indigestion, flatu- lence, diarrhoea, etc. The danger attending the use of iron in phthisis is the pro- duction of haemorrhage ; Churchill says : " Not only was haemor- rhage produced in almost every instance in which I used the Hy- pophosphite of Iron, but in patients who have been previously taking ferruginous medicines, it will be found that it is very diffi- cult at first to keep the effects of the Hypophosphite within the limits of their physiogenic action." Potassium is a powerful resolvent of condensed and consoli- 86 Alcohol-Cod Liver Oil. 87 dated lung tissue, causing softening of tubercular matter with a rapidity that may be dangerous and alarming. The depressing action of potassium is also well exemplified in the effects produced by iodide of potassium, which, as physi- cians know, causes prostration, indigestion, loss of appetite, etc. This action is largely attributable to the potassium base. Arsenic and Metallic Salts. - ' ' Arsenic, which is fre- quently prescribed against phthisis, almost entirely destroys the beneficial action of the Hypophosphite. The same remark ap- plies to all metallic salts in general. " Alcoholic Drinks.-All alcoholic stimulants, strong wines, and beer, which are so often prescribed in cases of consumption, produce similar effects. They prevent the return of strength, and bring on a recurrence or an aggravation of cough, fever and sleeplessness. " As their effect upon the system consists in a diminution of oxidation, it is directly contrary to that of Hypophosphite. ' ' Their use is to be more especially deprecated whenever there is any acceleration of the circulation, either owing to hectic fever, or to intercurrent inflammation, whether this latter be accidental or dependent upon softening of the tubercular matter. " Cod Liver Oil produces a somewhat similar effect to that of alcoholic stimulants. It disturbs digestion, interferes with the appetite; by its local action on the lungs it hinders the elimina- tion of tubercular matter, favors the fatty degenerescence of tis- sue, to which the patient is already prone ; diminishes oxidation, thus increasing, without any beneficial effect, the plethora, which the Hypophosphite itself already tends to produce, and in this way frequently brings on formidable attacks of haemorrhage." Dangers of Salts of Potassium and Ammonium.-" The salts of Potassium and Ammonium are possessed of a special eliminative action. This explains why some practitioners, by the injudicious use of them in consumption, have seen the disease all the more rapidly run its course to a fatal termination."- Churchill. Dyspnoea.-"A phenomena often noticed and often re- Over Dosing. 88 ferred to by the patients in these cases, is their great breathless- ness ; they feel well, they say, ' but for breath.' This harassing dyspnoea I have now recognized as one of the phenomena of phthisical convalescence, when the destruction of lung tissue has been extensive."-Thorowgood. " Death.-When death takes place in cases treated by Hypophosphites, it is due either to the pre-existing lesion, or to the occurrence of some secondary or accidental complication. In no case after the employment of Hypophosphites is death brought about by new tubercular deposit, unless the treatment is completely stopped while the patient is still exposed to the causes which produce tuberculosis." Over-dosing.-The pathological effects of over-dosing are disastrous. By increasing too suddenly the force of the circula- tion, without giving time for increased nourishment and strength to the texture of the weakened and impoverished blood vessels, the tissues of which have been appropriated by the urgent need of the general system, as from lack of proper assimilation of food, the patient has been living upon his own tissue-a haemorrhage ensues. The crisis is directly referable to the sudden over stim- ulation of the circulatory system, beyond the capacity of the blood vessels to resist. Another result of over-dosing is a too ac- tive disintegration of the tubercular deposit, causing a crisis by sloughing. This process, which is therapeutically desirable, must not go on too fast, beyond the strength of the patient to bear. Time is a necessary and indispensable element in the re- cuperative process. It must not be forgotten that all the func- tions must improve together, as new tissues must form and meta- morphosis take place, and morbid and prurient matter be elimi- nated ; hence, care should be taken, constantly watching for pathologic phenomena, never running risks because the patient shows, at first, brilliant results by large doses, for he will soon cross the line upon dangerous ground, a sudden relapse will put him back, and in advanced cases may cause death. While the smallest doses should, therefore, be administered at first, and gradually and watchfully increased as the patient is 89 Complications. found to bear them without showing signs of pathologic effects, the limit or maximum quantity to exhibit during twenty-four hours should not exceed seven grains, and in many cases, espec- ially when the disease is far advanced, this quantity will be found too great.* In such cases the Elixir Hypophosphite Quinine, or Pills of Hypo-Quinidol (Gardner) should take the place of the alkaline hypophosphite, f until the patient has gained sufficiently to safely bear either the Eime, or the Soda Syrup, in at first, very small doses. Complications.-In Phthisis, complications must of course be treated by appropriate remedies, but during such treatment the use of the Hypophosphite should be suspended. Unless dur- ing such crisis, no other medicine should be given, reliance be- ing placed entirely upon the Hypophosphites to relieve cough, night sweats, etc. Narcotics and stimulants should not be used if the Hypophosphite treatment is adopted, as they prevent the proper effect of the remedy, and lower the vital condition of the patient in the end, though they may apparently lessen some of the urgent symptoms. If the patient is not progressing be assured there is a rea son for it, and, generally, one that can be controlled. Do not blame the remedy when the fault is because of its inconsider- ate use. Either the wrong salt is being administered ; or, what is worse, a combination containing contra-indicated salts ; or some other remedy is being used which prevents the favorable action of the Hypophosphite; or the dose is too large ; or the patient is suffering from a complication which interdicts the use of the Hypophosphite for the time being ; or the Hopophos- phite is impure, and consequently unable to produce favorable results. * Gardner's Syrups ofC. P. Hypophosphite of Soda, and C. P. Hypophosphite of Lime contain Twenty (20) grains of the salt in each fluid ounce, or two and one-half (2%) grains zn each dfam (teaspoonful). The maximum dose of either of these syrups, therefore, in Phthisis, is three teaspoonfuls in twenty-four hours. t In speaking of the " Alkaline Hypophosphites '' reference is made to the hypophosphites of the " Alkali" metals, Sodium, Potassium, etc. These salts, however, when pure, do not have an alkaline reaction. Anabolism. 90 " With regard to the patient's diet it will not be found neces- sary, while he is taking the Hypophosphite, to prescribe or to forbid any special kind of food, provided the digestive powers be unimpaired; otherwise it may become necessary to order some special regimen. " It is far better to stimulate the patient's appetite by the variety of his diet. ' ' DIET. " The following precautions must always be observed. If tuberculosis depends upon the want of oxidizable phosphorus in the system, it is clear that the introduction and assimilation of the Hypophosphite will supply this want, but this phosphorus does not exist in the organism in an isolated or free state. It is only one, although the most important and characteristic, among several other principles which unite to make up the phosphide, or oxidizable phosphorized proximate principles. These other elements must be provided by the organism, must combine wdth the new element medicinally supplied, and the resulting com- pounds must be built up in the system itself. This is a process of integration which depends, it is true, upon the presence in the system of the elements required, without which it cannot take place, but which is influenced by the activity of other functions, and above all by those of assimilation, respiration, and sanguifi- cation. Now each of these three different functions may vary, and do vary, in every individual, so that even should the phos- phorized element be always supplied in the same quantity, it will not be worked up in all cases with the same amount of activity. It is evident, for instance, that a patient in whom the appetite or digestive function is impaired will take less nutriment, even if he takes the same amount of phosphorus, and consequently build up less of the principles containing the phosphide element, than one in whom the digestive functions are sound. The same will be the case when the lungs are seriously damaged and the respi- ratory power considerably impaired. PRECAUTIONS. Plethora. " The improvement of a consumptive patient under the Hy- pophosphite should be slow and gradual. The more advanced the disease, the more gradual should be the improvement and the more serious will be the induction of pathologic symptoms. This last circumstance is the more important, because the existence of a relative state of plethora is the prime condition of cure, but it is also at the same time a predisposing cause of hypersemia of the lung tissue surrounding the tubercular matter, consequently of inflammation and of softening of the tubercular deposit. " I have often seen cases in which the use of excessive or too prolonged doses of the Hypophosphite has brought on rapid soft- ening of the tubercular deposit and a fatal issue in patients, who shortly before had appeared in a fair way of recovery under the treatment. ' ' When there is any predisposition to haemorrhage, the action of the Hypophosphite should be carefully watched. This, how- ever, is not a counter-indication to its use. It frequently hap- pens, on the contrary, that the tendency to haemorrhage disap- pears under their influence. I have published several cases in support of this view, which have since been confirmed by other observers. "Asi have seen cases of softening induced by overdoses of the Hypophosphite, so likewise I have either known of, or have witnessed attacks of haemorrhage, evidently owing to the same cause, or to the concurrent use along with the Hypophosphites of Cod Liver Oil or of Iron ; sometimes to the injudicious use, in lieu of the Hypophosphite of Soda, or Lime, to the Hypo- phosphite of Iron, or even of free Hypophosphorous Acid, given by the physician on account of their greater activity ; to the over excitement of the circulation by stimulating liquors; or, lastly, to the use of a heterogeneous jumble of different Hypo- phosphites ; oftentimes, alas! for the poor patient, to a mass of powerful therapeutic agents dished up together. " I remember among many similar cases a consumptive child, nine years of age, who had been ordered to take every day a tablespoonful of Syrup of Hypophosphite of Iron, a large dose 91 Signs of Improvement. 92 of cod liver oil, a powerful tonic and a glass of port wine. " I will now examine successively two different kinds of re- sults which may follow upon the use of the Hypophosphites. "Supposing that the primary condition, that of purity of the remedy, has been secured, I find that when an improvement does take place, the first signs of it usually show themselves more or less during the first week. Sometimes the patient noti- ces it from the very first day. It is seldom delayed beyond a fortnight, though in some exceptional cases I have known it not to become apparent till after the lapse of as long a time as six weeks. You must not, therefore, despair of the remedy if its action be not immediately manifest. Sometimes the improve- ment is apparent for all the symptoms at once ; sometimes only for some ; at times for a single one. The appetite is sometimes the first function to improve. At other times it is the strength, or it may be the cough, or sleep, or perhaps fever. The younger the patient, the more limited and the more recent the disease, the shorter is the time usually required for the first reappearance of improvement." " Narcotics, Opiates and Sedatives produce a contrary ef- fect to that of the Hypophosphite. They prevent the return of ap- petite, they bring on or increase weakness and night-sweats. When, as is frequently the case, the patient has been under pallia- tive treatment of this kind for some time previous to his taking the Hypophosphites, the action of the latter will generally be delayed thereby. When narcotics or sedatives have been used for the purpose of allaying harassing cough at night, it will frequently happen that their suppression will be attended with more or less distress to the patient. But it must be persisted in if we wish to obtain the effects of the specific treatment. ' ' Of late years several pharmaceutical preparations have been largely advertised, which consist of a heterogeneous jumble of Hypophosphites, most of which are positively injurious in con- sumption, as I have before said, and could only be prescribed by a practitioner who understood the matter, if it were wished with deliberate purpose that a patient should only improve for a time Time for Administration. 93 and ultimately not get well. These different Hypophosphites are usually associated with strychnia. A mere inspection of them suffices to show that in a pharmaceutical point of view they are utterly ridiculous, if the word monstrous would not be more deservedly applied in a case like this, where the lives of thou- sands of persons are at stake. It strikes me as wonderful beyond belief that such preparations should by pertinacious quacking have received such acceptance among the profession, and that a medical journal could have proposed that any such as these should be inserted in the British Pharmacopoeia. ' ' CAUSES OF ERROR. ' ' Not a week passes without my meeting with cases where consumptive patients are going to the bad after a temporary im- provement derived from the use of these preparations. * " It is thus seen that there exists a number of serious causes of error which should be carefully avoided, as they may easily be, when they are once pointed out. It will occasionally happen that the patient will look upon certain disturbances following the action of the Hypophosphites as unfavorable, and be thus induced to give up the treatment. Such are the following : The morn- ing is usually the best time to give the Hypophosphite, but in children and in delicate, highly nervous persons, if the remedy be taken in the morning, its stimulating effect will sometimes be- come apparent during the night, and the patient will complain of restlessness and want of sleep. This will usually be got rid of by changing the hour of administration. " By giving the remedy at bedtime, absorption and assimila- tion take place during the night, and its physiologic effects of increased comfort, strength and activity will then manifest them- selves during the day. "Sometimes the patient's appetite increases considerably, but the digestive power, owing to the still deficient supply both in the quantity and the quality of the blood, has not improved in the same ratio. The patient, therefore, complains of increased difficulty of digestion. Appetite-Digestion. 94 "This is attributed to the Hypophosphites, and they are struck out. By observing the very simple precaution of keeping at first to the same regimen, and the same amount of food, and only changing and increasing them by slow degrees, this appar- ently unfavorable effect of the Hypophosphites will be seen to be a result of the efficacy of their action. " Many cases, however, of gastric disturbance noticed by other observers have been undoubtedly due, not to this cause, but to the impurity of the salts used. ' ' In the use of these remedies one should never lose sight of the necessity of advancing slowly and gradually along the whole line of improvement. There must be no sudden spurt or burst, and no one function can be stimulated physiologically and use- fully to the patient, unless the others are able to follow and keep up with it." NECESSITY FOR DISCRIMINATION IN THE SELECTION OF HYPO- PHOSPHITE SALTS. " The too prevalent idea that phthisis, if curable by the Hy- pophosphites, is to be cured by any of these salts, given in any dose or at any time, shows the low state of medicine as compared with that of really exact sciences." " If ten consumptives be selected in such a state that there can be no doubt of the certainty of the diagnosis, and at such a stage of the disease that the pulmonary lesions shall be as little advanced as is compatible with such certainty, it is un- deniable that no physician would pledge himself to cure a fixed proportion of them, or even any one single case selected before- hand, if he be debarred from the use of the Hypophosphites, or of some oxidizable compound of phosphorus. " With every other resource at his command, the utmost he could do would be to promise that the life of some of them might be prolonged ; that one, or at most, two, might possibly escape, but without being able to tell who would be the fortunate excep- tion, or who would prove victims to the disease. PROGNOSIS. Prognosis. 95 "On the other hand, if any number of patients be taken in the conditions above indicated and subjected to the use of the Hypophosphite properly given, nine out of ten of them ought to recover, the tenth case being allowed for errors of observation. So that the prognosis of a given case of phthisis, either treated by the ordinary means exclusive of the Hypophosphite, or left to the course of nature, depends not on the state of the patient, but on the nature of the disease itself, and is nearly always fatal; while the prognosis of the same disease under treatment by the Hypophosphite is independent of the diathesis or constitutional cause, and rests altogether on the extent of the pre-existing le- sions, that is, on the destruction of lung tissue already produced, or on the presence or absence of complications." COMPLICATIONS, " I now come to a very important point-that which relates to the influence which the existence or non-existence of compli- cations exerts on the cure of phthisis by the Hypophosphites. ' ' The complications of consumption are of two kinds ; some are secondary or tertiary consequences of the disease itself and are nearly sure to appear at certain stages of its development. Such are haemoptysis, diarrhoea, amenorrhoea, vomiting, fatty degeneration of the liver, disease of the kidneys, etc. " Others are distinct diseases, co-existing with the principal complaint. Such are accidental intercurrent inflammation of the different parts of the respiratory apparatus, bronchitis, pleurisy, pneumonia, laryngitis. The first kind of complications may be called consecutive ; the second, accidental. " Oedema of the extremities, when not dependent on an ac- companying affection of the heart, is always a very serious symp- tom in relation to phthisis, since it indicates the existence of a con- siderable mechanical obstacle to the circulation, due either to the extent of the lesion in the lungs, to fatty degeneration of the liver, to disease of the kidneys, or to embolic disease of the veins, and is usually indicative of a speedy, fatal termination. In four cases, however, I haveiseen the patients recover after well marked, oedema. Haemoptysis-Haemorrhage. 96 " Aphthae, which is pathognomonic of a general failure of the nutritive function, is a still more fatal symptom than oedema. " Haemoptysis.-In the prognosis of haemoptysis a distinc- tion should be drawn between the result of a given attack and that which depends on the haemorrhagic tendency of a patient. The first varies with a number of circumstances which it would be too long to investigate here. The second case, namely : The existence of the haemorrhagic predisposition, will render the prognosis less favorable than it might otherwise be, for two rea- sons : First, because the patient may be suddenly cut off by haemorrhage, and next, because there will be need of greater caution in the use of the Hypophosphites. " Vomiting may depend upon two causes. At the beginning of the disease it is usually produced by the intensity of the cough and does not modify the prognosis, since, when this is favorable in other respects, the vomiting almost always disap- pears on the patient's improving, and no necessity exists for any special treatment. " When, however, the vomiting depends on the state of the digestive organs, the prognosis is less favorable, as it must be based not upon the simple existence of the symptom, but upon the whole morbid series, of which it is only one sign. " These vomitings usually produce great weakness, because they directly interfere with nutrition, and have been heretofore looked upon by pathologists of the anatomical school as depend- ent upon softening of the mucous membrane of the stomach. This is an error which I pointed out many years ago. The soft- ening found on post-mortem examination in cases of this kind is an effect of cadaverous decomposition. " The vomiting is always proportionate to the violence and frequency of the cough, and disappears as soon as the latter is reduced to its minimum by the action of the hypophosphite. "In some few cases, however, vomiting, or rather nausea, seems to be connected with renal or uterine complication. "Fever and Night Sweats.-Hectic fever and nocturnal Fever-Night Sweats. ephidrosis are generally a consequence of the purulent resorption which takes place in the lung tissue. If the disease is recent, both symptoms usually disappear by the aid of the hypophos- phite alone, because they depend either upon the resorption of tubercular matter, or upon the general debility of the patient. When the disease is more advanced, when the tissues of the lungs are deeply disorganized, and purulent secretion is fully established, perhaps by the formation of a pyogenic membrane, this result cannot be obtained, or can only be obtained very slowly by the hypophosphite. " Diarrhoea at the beginning or in the course of the disease, and not depending on ulceration of the intestines, nearly always yields to the action of the hypophosphite alone, as is mostly the case in children, or to appropriate adjuvant remedies ; it, there- fore, calls for no modification of the prognosis. Yet, as this is a point which is often very difficult to decide, the prognosis in such instances depends chiefly on the intensity and the persistence of the complication, whatever be its cause, since this always pro- duces a disturbance of nutrition. " When diarrhoea is present, the prognosis ought, therefore, to be given with great reserve, until we are sure of being able to combat it successfully. " Colliquative Diarrhoea is only one of the numerous symp- toms of organic lesions involving nearly every part of the body, and is necessarily fatal. I have, however, more than once been called in consultation to a case of phthisis with colliquative diar- rhoea, and all the concomitant symptoms of an expiring patient, and have been told by the attending physician that he thought it an excellent opportunity for trying the effect of the Hypophos- phites. " Fatty Degenerescence of the Liver, when it has reached a certain extent, is also an unfavorable symptom, though I think it has not the importance which some pathologists have assigned to it. " Laryngitis. --The prognosis of phthisis complicated with laryngitis, under ordinary treatment, is, as is well known, almost 97 Laryngitis. always fatal. Of all the complications of phthisis this is per- haps the most formidable, and tubercular laryngitis has hither- to been looked upon as absolutely incurable. It was observed in ten patients out of seventy-nine. "There were four confirmatory (continued improvement dur- ing whole time of treatment) results, of which two were cures, and six negative results, including three deaths. In my private practice, the results with the Hypophosphites have been more favorable than this. " Amenorrhoea, which shows itself at the beginning of phthisis, not yet under the Hypophosphite treatment, is usually not of much importance, as it may then depend on the general condition, and on imperfect haematosis. " When it appears in the course of the Hypophosphite treat- ment, it may be produced by different causes, such as the break- ing down of the pre-existing tubercular deposit, or intercurrent inflammation. " In such cases, it is always a bad sign, though not necessar- ily fatal.''-Churchill. 98 THERAPEUTIC EFFECT NOTED BY DR. CHURCHILL IN SEVENTY- NINE CASES TREATED DURING ONE YEAR AT HIS PUBLIC DISPENSARY, PARIS. "Fever.-Forty-four patients suffered from fever. In 24, the fever diminished ; in 37, it disappeared, but only perman- ently in 16. Total number of cases influenced, 41 out of 44. " Night Sweats.-Night sweats were noted in 56 cases. They diminished in 9 and ceased in 44 ; but for 11 of these, only for a time. For three patients the record is incomplete. Total number of cases influenced, 53 out of 56. " Loss of Appetite.-Fifty-two patients had lost their appe- tite. Improvement in 11 cases ; complete return of appetite in 39 cases, which for seven of these was only temporary ; record incomplete for two cases. Total number of cases influenced, 50 out of 52. "Vomiting.-Twenty-one patients complained of vomiting. Churchill's Results. 99 Four improved ; in 13 it disappeared, but afterwards returned for five out of that number, in one case the result was not noted. Total number of cases influenced, 17 out of 21. "Sleeplessness.-Thirty-six patients complained of want of sleep. In 15 cases there was an improvement; 17 cases recov- ered sound sleep, but 3 of these only for a time ; for 4 cases the record is incomplete. Total number of cases influenced, 32 out of 36. " Dyspnoea.-Seventy patients complained of shortness of breath. In 25, the breathing improved ; 38 recovered their nat- ural breath, in 1 case this was only temporary; in 5 more cases the change was not noted. Total number of cases influenced, 63 out of 70. " Cough.-All the 79 patients had cough, there was an im- provement in 43 cases; in 31 it ceased altogether, but in one of these afterwards returned ; in one case the result is not stated. Total number of cases influenced, 74 out of 79. " Expectoration.-Expectoration was noted in 76 patients. There was an improvement in 39 ; it ceased altogether in 27, but in 5 of these afterwards returned ; in 1 case no record of change was made. Total number of cases influenced, 66 out of 76. " Diarrhoea.-Ten patients were suffering from diarrhoea. It ceased in 8 cases. Total number of cases influenced, 8 out of 10. " Menstruation.-Dysmenorrhoea was noted in 6 cases. Two patients improved ; in the four other cases the function was restored to its normal state, but for two of these only for a time. Total number of cases influenced, 6 out of 6. " Amenorrhoea.- Existed in eight cases, and in six the function was restored. Total number of cases influenced, 6 out of 8. " Strength.-As far as muscular power is concerned, 48 pa- tients had been obliged to leave off work altogether; 27 were able to return to their occupations, but 4 only for a time. Total number of cases influenced, 27 out of 48. ' ' The above is a summary of the symptomatic modifications produced by the use of the Hypophosphites. ' ' Churchill's Results. MODIFICATIONS OF SYMPTOMS UNDER TREATMENT. 100 " In nearly every case, one or several of the morbid phenom- ena were diminished or modified at least for a time, so that there was at least an improvement, even if only temporary, in almost every case. ' ' The changes produced by the treatment in the percussion and auscultatory sounds may be of three different kinds ; there may be a complete disappearance of the morbid sounds ; there may be simply a decrease, or there may be a passage from one kind of morbid sound to another after an aggravation of greater or less duration. " In many cases the local signs which are pathognomonic of tuberculosis in the second degree, may disappear completely with- out leaving any trace behind, which authorizes the conclusion that this has been effected by resolution and absorption of the tubercular matter. Until my discovery of the Hypophosphites, this mode of cure had been observed so rarely in consumptives arrived at the period of softening, that most pathologists either denied or doubted its possibility. But there can be no doubt of the fact for those who have seen the curative action of the Hy- pophosphites. Out of the 79 cases to which reference has al- ready been made, this occurred for 16 cases. But I have since then observed this result in thousands of instances. It will be found to have occurred in 7 of the 20 cases in the third stage ob- served by myself. *1 In these cases one lung was in the third stage, and the other in the second stage; the latter organ was entirely restored to health. A similar result will be found in several of those which have been published by other observers, and which are given in the same appendix. " Sometimes, although recovery takes place, a portion of the lung, which had been the seat of the disease, remains indurated or consolidated. " There is probably either encystment,cretification, or incom- plete elimination of the tubercular matter, or the lung tissues have permanently consolidated and indurated. Cicatrized Excavations. 101 "This result was noted in 6 cases of the 79 already referred to. " In another class of cases recovery only takes place after complete softening of the morbid deposit, which ulceration of the lung tissue involved, and the formation of an excavation. This occurred for 4 cases in the series of 79. " But in Appendix III. {Churchill's Work), will be found an- other series of twenty cases of the same kind, collected from my private practice, in the course of little more than two years of my first use of the Hypophosphites in Paris. " Although this mode of cure in consumption had been occa- sionally noted previously to the use of the Hypophosphites, it was of such rare occurrence that very few practitioners had been able to observe more than one or two cases in a long series of years. " With the use of the Hyoophosphites this mode of termina- tion is one of frequent occurrence. I am probably under the mark in saying that I have now observed several hundred cases of this kind. But in instances terminating in this way, as also in the preceding one by induration, the final condition of the pa- tient may vary in different cases. In some there will be no gen- eral symptoms at all left, not even shortness of breath ; the pa- tient will be able to undergo as much, or nearly as much, exer- tion and fatigue as before. There may be no cough, no expec- toration, and the patient may enjoy robust health ; while even here, the pectoriloquy and cavernous breathing will give unde- niable proof of the existence of a cicatrized excavation." " Condition of Cure.-In other instances the lung tissue, which has not been destroyed, may not have been so completely restored to its normal condition, or the cavity may be more ex- tensive than in the former case ; and then, although the arrest of the original disease may be as complete as in the former in- stance, though the tubercular diathesis-the fons et origo mali- may have entirely disappeared-though there may be no tend- ency to its recurrence, and consequently to a relapse, the pa- tient's health may not be so completely restored as'in the first instance, and may present every intermediate shade of difference between perfect ease and comfort, except during violent exer- Acute Phthisis. 102 tion, and a very unstable degree of well doing, where the amount of vital and organic activity remains very low, and where the pa- tient is a sufferer from every external variation, and where the lungs are in a constant state of accidental congestion or inflam- mation. This state of things will be more or less strongly marked, according to the amount of lung tissue which has been destroyed, or more or less damaged by the disease. " It will generally be found gradually to improve with proper care, and, above all, the avoidance of cold and exposure, particu- larly if the patient winters in a warm climate. This progressive condition usually lasts for two or three years, at the end of which period only, the patient may be said to have reached the full im- provement of which his condition is susceptible. " Conditions of These Results.-The question now oc- curs, when are these several results obtained by the use of the Hypophosphite? Is it merely by chance-that is, ow'ing to some undetermined cause-as in the cases of cure obtained by other means? No. It is in every case, where the remedy is prop- erly used, and where the patients at the beginning of the treat- ment are in such a pathological condition that a cure is still possible. " What these conditions are has been already explained, and there is no undue assumption in saying that the prognosis of no disease has hitherto been established upon a more aecurate basis. " I have shown that the primary condition for a cure depends upon the extent of the tubercular deposit. The second condition is the degree of evohition which that deposit has already reached. When that has not passed the second degree, and the disease is limited to one. lung, a favorable prognosis may be laid down with almost mathematical certainty. " A third condition is the acute or chronic type of the com- plaint. " As regards this type of the disease, i. e., its more or less rapid progress, the prognosis depends on the fact that the Hypo- phosphites have a specific antagonistic effect on the development of the disease. Acute Phthisis. " The more rapid the progress, the more serious, other things being equal, will be the prognosis, since the greater in a given time will be the extent of the lesion. "An amount of disorganization, which in ordinary cases would have required several months, sometimes in an acute case takes place in an equal number of days. Still, the principle already laid down, viz., that it is the extent of the lesion, which deter- mines the prognosis, applies as correctly to acute phthisis as it does to chronic. The acuteness of the disease, that is, the in- tensity of the general symptoms, has no influence on the efficacy of the treatment, and this is a result of which no other treatment offers a single example; for I am not aware that there is a single case of recovery from acute phthisis on record. I had, up to the year 1862, obtained this result in six instances, by the use of Hypophosphites, and since then have observed a number of others.* ' ' A fourth and last series of conditions depends upon the ex- istence or non-existence of complications. In a word, the prog- nosis of a case of phthisis, when subjected to the rational use of the specific treatment (chemically pure Hypophosphites, exhibited as separate salts, in accord with his suggestions), depends almost entirely on the pathological state existing at that moment, and a cure may be expected in all cases where the organic disease is not already sufficient to produce death, either directly by itself, or by the consecutive disturbance caused by its natural evolution. These are the limits of all real science, because all real science can only be conditional. To ask for more would be absurd, to pretend to do more would be an imposture.'' " Necessity of Accurate Auscultation.-The importance of accurately determining the site, the extent and the degree of the local lesion, in order to find a sure basis for prognosis, re- quires that a new view should be taken of the local diagnosis. "The full value of accurate auscultation now becomes appa- 103 * Dr. Churchill here draws a distinction between acute softening and acute tuber- culization. Hitherto, this distinction would have been of no importance, but becomes of the greatest value if the Hypophosphites are the remedy for the latter, but not the former. R. W. G. Auscultation. 104 rent, and practitioners for the future, instead of simply auscul- tating a patient for the mere purpose of deciding whether he is or is not consumptive, must examine him with the same attention and minuteness as in a case of pneumonia, or pleurisy, or heart disease. Without the resource of the Hypophosphites, it is a matter of small moment to the patient and his friends to deter- mine whether one or both lungs be involved, whether the deposit occupies a large or a small portion of these organs. The final result will in all cases be pretty much the same, and is merely a matter of time. " It often happens that in examining a case of phthisis the auscultator will diagnosticate the tubercular deposit as extending no further than where the lung gives signs of softening, while in reality a much more considerable portion may be invaded by tubercles in the crude state to such a degree that the respiratory process going on is barely sufficient to maintain life, as shown by the amount of dyspnoea. This latest deposit of tubercular mat- ter may sometimes be so far advanced that it must necessarily go on to softening, or this process may be set up by the slightest amount of intercurrent inflammation. Not only therefore must the examination of the chest be made with all the care and accu- racy the practitioner is capable of, but his diagnosis of the extent of involved lung must be based, not upon the physical signs alone, but also upon all the rational symptoms which can throw any light upon the subject. As in the diagnosis of the nature of the disease itself, so also in that of the amount of physical lesion, the only sure basis is the concordance of both the physical and the rational phenomena. It may sometimes happen that even an experienced and skillful physician, by taking account exclusively of the auscultatory signs, will think the local mischief is but slight, when it may already be very serious indeed-perhaps even hopeless. This will generally be indicated by the want of that proportion and concordance between the local signs and the intensity of the general symptoms, and, above all, the amount of difficulty of breathing which I have just mentioned. This is particularly applicable to cases of rapid tuberculization. Auscultation. 105 " I have seen several cases of consumption where the most eminent auscultators have neglected accurately to state the ex- tent of the local lesions in their diagnosis, even when given in writing. ' ' Two such cases will be found fully reported at pages 620 and 621 of my French work (De la cause immediate de la Phthisie, etc., Paris, 1864). " The subject of the first of these cases was a Russian Prince, who is now living, and has been in the enjoyment of perfect health for upwards of fifteen years, thanks to the use of the Hy- pophosphites, and who, the day before he was placed under my care, had been examined by three of the most eminent physicians and auscultators, I may say not only in Paris, but in the whole world. There is not an auscultator of any fame in this country, who, like myself, has not sat at their feet, or at those of their disciples. One gave as his diagnosis-" softened tubercules at left apex ; " another, " softened tubercles at right apex ; " while the third stated, "softened tubercles at both apices." On examination, I found these three statements were all correct, and that, moreover, there were a certain number of tubercles disseminated throughout both lungs. Now, what was the cause of these discrepancies? Simply that these gentlemen thought it sufficient to establish the nature of the complaint, that neither of them supposed there could, at this stage, be any doubt as to the ultimate prognosis, and the two first deemed it useless to alarm the family any more than was absolutely neces- sary. The discovery of the specific of phthisis now enables the practitioner to make the fullest use of Laennec's wonderful in- vention and to lay down the prognosis of tubercular disease with an accuracy inferior to that of no other branch of medicine, or even of surgery itself." " Apparent Aggravation.-The reader must not suppose that the results above described are attained smoothly and uniform- ly in all cases ; sometimes, as already mentioned, it is only after a temporary aggravation of the auscultatory signs that the lung is freed from the tubercular deposit. In these cases these signs Apparent Aggravation. 106 will be often found to undergo a gradual and progressive trans- formation from above downwards, as if the lung were composed of different layers of diseased tissue exactly in the same order as we know the tubercular matter itself is deposited. For instance, moist or dry crepitus apex ; lower down there may be dullness on percussion, and as yet nothing more than peurile, or bronchial, or diminished respiration. The crepitus may disappear at the apex, be succeeded by natural breathing, and then be found lower down, where previously there were no signs of softening. " These in their turn may also disappear and again be repro- duced for a while in a lower portion of the lung, so that for a time there may appear to be a local aggravation of the disease, although the patient is really on the high road to recovery. " The circumstances which appear most to favor a cure by resolution are the recentness of the deposit, the incipiency of softening, the freedom during the treatment from accidental in- tercurrent bronchitis, lastly, the youth of the patient. This last condition agrees with the well known fact that cavities are of a rare occurrence in young children. " When these conditions do not exist the softening of the de- posit must go on, and a cure can only take place after the forma- tion of a cavity. " Relapse.-What is the final value of the result obtained in a case of phthisis, when the lung has been completely healed, or when it has become cicatrized by the use of Hypophosphite ? Is the patient safe, or is he at any time subject to a relapse? Sev- eral hundreds of patients who have been cured by me in the first or second stage by the process of absorption or elimination of the tubercular matter, and whom I have had an opportunity of ex- amining since their recovery, have remained in perfect health by means of the occasional use of the Hypophosphite in prophylac- tic doses. ' ' Of the patients who had only recovered with the persistence of a greater or less amount of disorganization in the lung tissue, all those who have come under my notice for the last seventeen years, and who have been able to take proper care of themselves, Relapse. and to avoid exposure to cold and over fatigue, have continued for years to enjoy nearly the same amount of health, if not more, as immediately after their recovery. " Some have since died of other and altogether different dis- eases. " Where health has not been maintained and there has been any return of lung disease, the relapse has always been owing to local, non-specific, non-tubercular inflammation (on this point I am particular), of a catarrhal or bronchial nature, induced by the weather or other external causes. The practitioner who has had but little or no experience in the use of the Hypophosphites, and still less faith in their efficacy, is often ready to mistake these accidental inflammatory complications for a recurrence of the disease and a recrudescence of the tubercular deposit. " The signs of accidental or incidental softening of tubercular matter, which was previously in a crude state, or else increased peritubercular hyperaemia, which is one of the conditions of reso- lution and resorption, are also sometimes mistaken for those of fresh tubercular deposit. ' ' Occasionally accidental inflammation of incipient cicatrices, or of tissue that was only consolidated, or transient inflamma- tion of new tissue, may equally be mistaken for a new tubercular deposit. " More extended experience, a due regard to the rational symptoms, and, above all, attentive stethoscopic examination, will, however, usually lead to a more correct opinion. " When the recovery is still recent, the stethoscopic signs, which may be those of congestion, bronchitis, or even of pleurisy, or pneumonia of different extent and intensity, usually occupy the seat of the primitive local lesion, and may thus mislead the inaccurate and inexperienced, above all, the preju- diced, practitioner. " I have seen several cases where accidental inflammation in an excavated lung, which had been cicatrized by the use of the Hypophosphites, has been mistaken for the very last stage of phthisis by the most distinguished physicians. 107 Relapse. 108 " Oue of the most delicate points for the physician's decision is the true moment when it becomes advisable to resume the specific treatment after the occurrence of accidental inflamma- tion. ' ' I therefore confidently repeat the assertion I made many years ago, that as long as the patient is kept in a proper physio- logical condition by the prophylactic use of the Hypophosphite, according to the rules which have been laid down, I have never witnessed a recurrence of a fresh attack of tuberculosis. Now all practitioners who have seen a large number of consumptive cases, know how frequently this happens, particularly in children, when the treatment is confined to the ordinary means, such as cod liver oil, tonics, etc. Even in the instances where, owing to the general condition of the patient, without any local signs in the lungs, there has only been a suspicion of phthisis, how often does it happen that after an apparent return to health, of greater or less duration, the disease shows itself a second time, too fre- quently in an unmistakable manner. The means which appear to have answered in the first instance are now seen to fail, and the disease runs its course to the fatal end. " These are the instances where the Hypophosphites again and again show their wonderful efficacy. I could relate any number of cases, observed at my dispensary at Paris, among poor and ill-fed children, where, whenever the Hypophosphite has been omitted beyond a certain length of time, the disease has reappeared, and has each time been arrested with the same suc- cess as at first. Such cases are true expcrimenta crucis, and dem- onstrate beyond doubt, the specific action of the remedy.''- Churchill. I.-"One of the characteristic phenomena produced by Hypophosphite in the system is the production of venous ple- thora. II.-This plethora is the condition of their therapeutic ac- tion against phthisis. CONCLUSIONS. Conclusions. III.-This therapeutic action must be limited to the physio- logic effects, which afford the measure by which we should be guided in the use of them. IV.-Beyond this limit their medicinal effects are either transient or incomplete, and are not followed by a curative result, even with the co-existence of all other necessary conditions. V. -The use of the Hypophosphite in too large doses, or for too prolonged a period, produces symptoms which I have called pathogenic, and is then apt to lead to accidental complications of variable degrees of intensity, which may bring on a fatal termina- tion, owing to this mistake in treatment, even though the patient otherwise offers all the conditions necessary for a cure. VI.-As happens for other cachexiae, the local lesion, which is the result and the anatomical sign of the tubercular diathesis, when once it has overpassed a certain limit, pursues the usual course of its evolution by virtue of conditions which are to a great extent independent of the initial morbid constitutional state. VII.-The cure of the diathesis is not, therefore, necessarily and immediately followed by that of the lesion, although that of the lesion cannot be permanent unless it be attended or preceded by that of the diathetic condition. VIII.-The recovery of a patient subjected to the Hypo- phosphite treatment will therefore depend upon the extent of the preexisting local lesion ; that is, of the gravity of the disorganiz- ation, which has taken place previous to treatment. IX.-When the tubercular deposit has not gone beyond a certain stage of its natural evolution, it may be reabsorbed and entirely disappear. This re-absorption may take place not only when the tubercular matter is still in a crude state, but even when it has already reached the stage of softening. X.-This second stage, of softening, is sometimes one of the phenomena intermediate between the therapeutic action of the Hypophosphites and their therapeutic effect. Sometimes it sim- ply precedes the re-absorption of the morbid deposit, at other times it will go on to produce ulceration, destruction of the sur- 109 Conclusions. 110 rounding tissues, and finally consolidation or a cicatrized excava- tion. XI.-The cure of phthisis by the Hypophosphite may there- fore take place in two different ways, either by the disappearance of the local lesions, and by a cessation of the physical signs which indicate their presence, or by the persistence during a variable period of time of less extensive pulmonary disturbance, which, however, does not interfere, or only partially interferes, with the general health, and which does not predispose the pa- tient to a recurrence of the original diathetic condition. XII.-If during the persistence of the local signs in the lungs, the patient be kept in hygienic conditions proportionately adapted to the gravity of the persisting organic lesions ; if he be maintained under the influence of the specific treatment at proper prophylactic doses ; * * * the stethoscopic and plessimetric sounds will be found gradually to improve until they lose their pathognomic character, or even entirely disappear. XIII.-Time is an indispensable element in the cure of a case of phthisis, and no other means can be substituted in its place. XIV.-An overdose of the specific remedy, instead of hast ening the patient's recovery, will often produce a contrary effect. The greater the extent, and the more advanced the stage of the pulmonary disease, the more important it is to keep this fact in view, because a contrary conduct will then, still more than at other times, produce accidental complications. XV.-As in almost all cases of phthisis the tubercular de posit takes place gradually and invades successive portions of ths lungs, there is always a greater or less lapse of time during which the local lesion is of secondary importance ; and until that point has been overpassed, every uncomplicated case of tubercular consumption may be cured with perfect certainty by the scientific use of the Hypophosphite. XVI.-Every practitioner who is called upon to treat a case of phthisis is therefore bound, not only for the sake of human- ity, but by the rules of medical science, to have recourse at once Conclusions. 111 to the Hypophosphites, instead of only using them as a last shift after the loss of irreparable tissue, and it may be of irreparable time wasted in administering drugs which are notoriously of no effect. XVII.-If the Hypophosphites be the specific of phthisis, they must a fortiori be its prophylactic or preservative remedy. XVIII.-As when rationally administered they never pro- duce any unfavorable effect, they should immediately be had re- course to in every doubtful case, or even when there is only a suspicion of consumption. XIX.-All these conclusions are now confirmed by the in- dependent testimony of physicians living in all parts of the world. XX.-In no instance have they been controverted, when the observer has carried out his experiment with care, and according to the rules laid down. Physicians who had been unsuccessful in their first attempts, have in later efforts and after greater experience in the use of the remedy completely confirmed my views. XXI.-The effect of the Hypophosphite on the tubercular constitution depends upon a general action of the system, which at a future day will come to be recognized as of still greater im- portance than their effects in disease. In our present imperfect social state, there is a constant tendency to increased disturbance of the conditions of normal nutrition, which is effectually com- bated by the use of the Hypophosphite as an occasional and temporary nutriment. This result can be obtained by no other means hitherto known, than the use of some one of the oxidiz- able phosphorus compounds, the best of which are the Hypo- phosphites. XXII.-By means of these therapeutical agents the functions of innervation or nerve power, of sanguification or blood forming process, and of interstitial mitrition, which are the three primordial functions in the animal system, may be kept or gradually raised to the very highest degree of intensity of which the organic con- ditions of the subject will admit." Summary. 112 i. The Hypophosphites of Soda, Lime and Quinine are the only ones indicated. 2. The Hypophosphite must be chemically pure. 3. They must not be combined for use in phthisis. Why not? Because they act in antagonism to each other, the different bases being indicated in different stages of the disease and the several salts differing in therapeutic action. Churchill never uses them in combination. All statements that he did or does are false and misleading. 4. The Hypophosphite should be used only in the form of syrup. Why ? Because as salts they will not keep in the proper condition, the protective action of the sugar being nec- essary to prevent atmospheric oxidation. 5. The pure Hypophosphites are neutral, not alkaline. 6. Soda is indicated in the incipient stage, as a rule, with ex- ceptions. q. Lime is indicated in the second and third stages, as a rule, with exceptions. 8. Hypophosphite of Quinine is indicated in the initial treat- ment of far advanced cases, to be followed by the Hypo- phosphite of Lime, or Soda, later on, when it can be borne. 9. Lime reduces expectoration, frequently causing cough ; the soda should then be used. 10. Soda mildly favors expectoration ; if too free, the lime should be substituted. 11. The tendency of the Hypophosphite is to create plethora. 12. While this condition is necessary to the cure, it favors hae- morrhage. 13. Discriminating dosage is therefore necessary. 14. Any Hypophosphite given too freely will produce patho- logic or toxic effects, such as a too rapid softening and expectoration of the tubercular deposit, lassitude, pros- SUMMARY OF CHURCHILL'S METHODS IN PHTHISIS. Summary. tration, headache, giddiness, fever, indigestion, loss of appetite, colic or diarrhoea, epistaxis and haemoptysis. These effects are produced more readily by some salts than by others. Of those used in phthisis, viz., lime, soda and quinine, the lime is the most apt to be productive of these undesira- ble results. 15. If weak and emaciated, or if the case be well advanced, let the commencing dose be very small, even one grain in twenty-four hours in some cases, and, if well borne, gradually increase, keeping well within the physiolo- gical effect. 16. The maximum quantity to exhibit in phthisis, during twenty-four hours, is seven grains. (See note * p. 89) 17. Do not give any other drug with a Hypophosphite. 18. Lay aside the Hypophosphite when combating complica- tions. 19. Cod liver oil is contra-indicated in any stage of the disease. Why ? Because it produces plethora ; the Hypophosphite also produces plethora ; when used together, such a plethoric state is produced that, to avoid haemorrhage, the Hypophosphite must be discontinued; the Hypo- phosphite being the remedy for the diathetic state, must be continued, or treatment is nullified. 20. All alcoholic stimulants are contra-indicated. Why ? They prevent the return of strength and bring on a recurrence or an aggravation of cough, fever and sleeplessness. As their effect upon the system consists in a stimulation of the circulation and a diminution of oxidation, they act contrary to that of the Hypophosphites. Mineral Waters and all alkalies are also contra-indicated as they prevent the action of the Hypophosphite. 21. You should usually get results within two weeks. If not, look for the cause. It will, generally, be found to be one of the following : 113 Summary. 114 The Hypophosphite is impure and incapable of producing proper results. You are producing pathologic effects by overdosing. You are using alcoholic stimulants, which prevent the action of the Hypophosphite. You are giving anodynes or other drtigs to allay cough, pro- cure sleep or control night-sweats. You are using contra-indicated Hypophosphites, or combin- ations of them, the bases of which are therapeutically antagonistic, or produce pathologic effects. You are giving cod liver oil along with the Hypophosphite. A complication has arisen which requires special treatment. The disease is so far advanced as to be hopeless. 22. Continue the treatment within physiogenic limits, intermit- ting every third week, until the diathesis is removed, and then use occasionally as prophylactic. The syrup may be given in milk, coffee, water, or in a little lemonade, if it is found to be more acceptable to the patient. 23. Night-sweats will yield, in time, to the Hypophosphite alone. 24. Complications must be treated as they arise, discontinuing the Hypophosphite in the meantime, but resuming it again when acute symptoms have subsided. 25. In case pathologic symptoms are accidentally produced, at once discontinue the Hypophosphite, and take it up again after ten days or two weeks, in smaller quantity. Clinical-Dr. De Bremon. 115 First, Second and Third Stages. Three Cases Phthisis Pulmonalis, Selected From 150 Cases Successfully Treated in New York City and Vicinity. BY THE LATE L. DE BREMON, M. D., NEW YORK CITY. UNIVERSITY OF PARIS (FRANCE). Knight of the Legion of Honor ; Member of the Order Imperial Ottoman Medjidie (5th Class) Member of the New York County Medical So- ciety, the Neurological Society of New York, and the New York Medico-Legal Society ; Late Clinical Assis- tant to Dr. J. F. Churchill, Paris,; Etc., Etc. Phthisis Pulmonalis in the First Degree-Cure- Time of Treatment-Four Months.-Case i.-Mrs. L., aged 32, residence, Brooklyn. This lady was advised by her physi- cians to spend some time in Germany, her native country, in the hope that the change of climate would stop a beginning phthisis pulmonalis. She was absent accordingly from May, 1879, until October, same year. When she returned to America, there was no amelioration of her condition ; on the contrary, her cough was more persistent, her appetite nearly gone, and she was much troubled with sleep- lessness and night sweats. I saw her at the latter part of October for the first time. On examining her chest, I observed on the left side, in the supra and infraclavicular region, a well marked dull sound, and also a notable diminution of the respiratory murmur, with slight crepitation (crackling noises). In the rest of the side the breath- ing was generally exaggerated (overstrained). Pulse 90; tem- perature 98% at the time of the examination. Amenorrhcea and very profuse leucorrhcea. The right lung was normal. Clinical-Dr. De Bremon. 116 Diagnosis.- Dry tubercles at the upper extremity of the left lung. Treatment.-Teaspoonful of the syrup of Hypophosphite of Soda (2% grains) three times a day at meal times. A week later, I saw my patient again. Her cough is less troublesome, her appetite has increased, she sleeps better, and her night sweats less profuse. Same treatment. In another week the amelioration was progressing without notable change. Same treatment for a fortnight. At the end of this period my patient called. She told me that her appetite had augmented notably, her cough was decreasing rapidly, and night sweats nearly disappeared. Pulse 80; temperature normal. Same treatment for the next fortnight. Two weeks afterward, I saw her again ; her general state had greatly improved ; she was growing more fleshy. On exam- ination I ascertained a very marked diminution in the crepita- tions which I had at first observed, the breathing was less exag- gerated ; the dull sound, although weaker, still existed. Same treatment for a fortnight. At the end of this time the general condition was progress- ing, her cough had subsided, her appetite was good, and the night sweats had completely vanished. Same treatment for the next month. When my patient visited me again, her general appearance had undergone a complete change ; her health was quite satisfac- tory, all the symptoms of the disease had disappeared ; menstru- ation had become regular, although leucorrhoea still persisted, for which I ordered : $ Zinci sulph. pulv. ; Acidi Tannici, aa 3 ij. M. Ft. chart. No. xvj. One powder to be dissolved in one pint of tepid water, and taken by injection (per vaginam) morning and evening. On examination, the chest on percussion sounded well ; all dullness had disappeared. On auscultation, I could find no more crepitation in the up- Clinical-Dr. De Bremon. 117 per part, breathing- had become normal, although a very slight noise was yet noticeable at the expiration. I ordered the treatment to be continued as a prophylactic, and reduced the dose to one teaspoonful (2% grains) of the syrup of Hypophosphite of Soda twice a day (breakfast and dinner). Five weeks later I saw my patient again. The general state of her health was as satisfactory as at the time of our last inter- view, and the slight noise noticeable at the time of expiration quoted above had entirely disappeared ; no more leucorrhoea. My patient was discharged cured, but as a prophylactic measure I told her to take one teaspoonful of syrup of Hypophos- phite of Soda daily, and continue for a period of about six months. I know that at the present moment Mrs. L. enjoys a perfect state of health. Phthisis Pulmonalis in the Second Degree-Cure After Six Months' Treatment.-Case; ii.-Mr. S., a resident of New York, set. 19, came to see me. His medical advisor, who occu- pies a prominent and well-deserved position in this city, had told him that one of his lungs was badly diseased, and that he was of the opinion that his patient be treated with cod liver oil and phos- phate of lime, emulsified, for which he accordingly prescribed. Mr. S. tried hard to follow the directions given, but each time his stomach rebelled, and finally rejected the medicine. He was then sent to me. He had complained for about eighteen months of a harsh, dry cough, and for two or three months he coughed a great deal before going to, and rising from, bed ; had lost a good deal of strength, and was becoming very much emaciated ; he thought his mother had died from consumption. April 25, 1879.-Cough every morning with expectoration of mucus, tinted with blood; night sweats ; appetite sufficiently sat- isfactory ; pulse 95 ; temperature 100% ; the patient complained of a pain in the back, level with the angle of the right scapula, and a shortness of breath when walking. On examination, I ascertained a well-marked dullness under Clinical-Dr. De Bremon. 118 the right clavicle over a space of about three centimetres. The resonance of the left side was normal. When I performed a rather deep percussion on the right side, my patient complained first of a sudden violent pain, and then fainted, which state lasted five minutes, his face turning pale and assuming an expression of terror, while thick drops of cold perspiration appeared on all its surface. I was compelled to put off my examination until the next day. When I resumed it expiration was weak in the upper and fore part of the right lung. The voice of my patient echoed, especially in the region under the right clavicle ; on the left hand side, fore region, his respiration was exaggerated ; on the right side, towards the rear, the resonance was much less powerful, and breathing very weak in the infra spinal fossa. Level with the spine of the shoulder blade (epine de 1'omo- plate) I observed several crepitations of a humid character ; in the rest of the lung, breathing was very faint, and the voice sounded very strong. Treatment.-One teaspoonful of the syrup of Hypophos- phite of Lime (2^ grains of the salt) three times a day at meals for eight days. At the end of this period the night sweats had greatly sub- sided. Same treatment for eight days more. On the 12th of May my patient was progressing favorably ; he said he was less suffocated when walking. On the 19th, no change ; general state was improving. On the 28th, on auscul- tation, I found that I could hear the expiration better in the right side, although the crepitation had not entirely disappeared and the voice was less sonorous. To the right, under the clavicle and*toward the external ex- tremities of the latter, the resonance was somewhat less than on the left side. In the fore region it was nearly equal on both sides; how- ever, to the right the voice was a little more sonorous than to the left. Clinical-Di. De Bremen. To the left, towards the rear, breathing was somewhat exag- gerated ; to the right, in the infra spinal fossa, I heard at inter- vals a few crepitations. In the rest of the lung it was normal. A faint echo was audible, however, level with the spine of the shoulder blade (epine de 1'omoplate). ' I reduced the dose of syrup (this time of soda) to one tea- spoonful, morning and evening, and advised my patient to spend a month in the country. When he returned to New York, in July, he felt all right; he was strong ; no cough ; no night sweats ; no dyspnoea. All the general symptoms had vanished. I ordered for two months more the treatment above de- scribed, as a prophylactic, viz., one teaspoonful of the syrup of the Hypophosphite of Soda (2% grains), once daily. Mr. S. came to see me later on, calling my attention to a slight touch of spermatorrhoea. As to his recent state, he told me he had never given it a thought since, as he had nothing to complain of. I have seen him since nearly every month in social relations, and his health is in perfect order. Phthisis, First Stage, Turning to Second.-Three Months' Treatment.--Cure.-Case hi.-Miss S., aged 19, born in New York. Expectoration, cough, night sweats, dys- pnoea, nearly complete loss of appetite, emaciated, no sleep, pal- pitation, amenorrhoea. She had begun coughing about four months before. The family physician had been sent for, had diagnosticated incipient tuberculosis, and had prescribed cod liver oil, cream and whiskey. This treatment had given no relief to Miss S. ; her stomach rejected the oil. I was then invited to see her, and the following were the symptoms : Complexion generally pale ; cheeks somewhat red ; emaciation considerable ; prostration intense ; expectoration not very abundant, somewhat pearly and mucous, and totally differ- ent from that caused by bronchitis. Right lung in the fore region, to the right and in the upper 119 Clinical-Dr. De Bremon. 120 part, the dullness on percussion was not very strong in the lung from its lower extremity up to the summit ; breathing was weaker than on the left side ; also several crepitations audible at its basis and right side. At the rear, in the inferior portion, I ascertained the exist- ence of very notable crepitations of a hurried character ; these were very strong and increased at the time of coughing. To the left, both in the fore and rear region, the respiration was a little exaggerated. Left lung perfectly healthy. I prescribed syrup of the Hypophosphite of Lime, one tea- spoonful in the morning and one dessert spoonful in the evening, at meals (about eight grains of the salt daily) ; added to this I prescribed a potion containing one-fourth grain of digitalis to the teaspoonful, in mucilage, to be taken only when palpitations were too troublesome. This treatment commenced on the 8th of March, 1890. I saw my patient on the 15th; her appetite was better; cough had decreased ; night sweats less abundant, and respira- tion easier. Same treatment during eight days. On the 23d.-No change worth mentioning. On the 29th.-Appetite restored ; sleep quite satisfactory ; no more palpitation. Same treatment for one week, omitting the potion with the digitalis. April 9th.-Progressing condition ; hardly any more cough. I reduced the daily dose of syrup of the Hypophosphite (this time substituting soda for lime) to a teaspoonful morning and evening. I was called April 13th.-Less satisfactory state ; cough somewhat stronger. Miss S. confessed that she had imprudently gone out on a wet day and had her feet soaking wet. I increased the daily dose to one and a half teaspoonfuls of syrup of Hypophosphite of Soda, morning and evening, for one week. Dr. De Bremen-Phthisis. 121 April 19th.-Patient better ; no bad results from her impru- dence ; good appetite prevails ; no night sweats and sleep satis- factory ; reduced the dose of the syrup to a teaspoonful morning and evening. April 26th.-Menstruation, which had been suspended, was recovered. Same treatment. May 3d.-No alteration worth mentioning The examination which I performed then set forth the fol- lowing evidence : All the general symptoms of the disease had disappeared ; there was no more dullness; no more crepitation at the basis of the right lung, the respiration, however, was still somewhat weak at the front, under the clavicle; no bellows sound in the heart, but the " first sound " was still dead. Same treatment. May 10th.-Progressing sanitary conditions; Miss S. begins to grow more fleshy, and was able to help her father in his business. Same treatment. May 17th.-On examining my patient, I could no longer discover any difference in the respiratory function on either side. My patient told me that she felt very well. I advised her family nevertheless to send her in the country, if possible, and to go on with the treatment as a prophylactic, viz. : one teaspoonful of syrup of Hypophosphite of Soda, daily for two months more. In regard to the diagnosis in the present case, it would cer- tainly, in some respects, be doubted ; the crepitations, of a hur- ried character, were limited to the basis of the right lung, but there was, besides, in all the rest of this organ, a very great diminution of the respiratory murmur, without any hissing sound, or ronchus, and there was also dullness in its upper por- tion. The considerable anaemia, the night sweats so intense, and the cough and expectoration relatively so insignificant, could not, however, be attributed to plain bronchitis. Dr. De Bremon also makes use of the following language which we abstract:-38 38 De Bremon, Phthisis Pulmonalis and its Treatment with the Hypophosphites. Dr. De Bremon-Phthisis. 122 " As we generally cannot rely on salts that are at our dis- posal in drug stores, the aim is to find a reliable preparation; and I will take the liberty of giving to the profession the result of my experience, after many trials of different preparations. I have found only two that fulfill the necessary condition for good therapeutic effect, viz., purity of the salts employed. Those to which I have given the preference, and the only ones that I exclusively employ, are the syrups of hypophosphite of soda and hypophosphite of lime, prepared by R. W. Gardner, chemist, New York City, and for the following reasons : First.-The salt used is perfectly pure, and keeps entirely unoxidized in the syrup. Second.-He alone has understood that the different salts have to be employed separately, according to the stage of the disease, hence his two different syrups-soda and lime. Third.-Because after many tests, at different periods, I have found them always the same, and the therapeutic effects obtained invariably good. In giving my preference to one preparation, when perfectly convinced of its constant purity, I have only followed Dr. Churchill's example, who has never employed any other prepara- tion than that made by Swan, Rue Castiglione, Paris, after he had become convinced, by repeated trials, of its purity. My reasons for not using other and combined preparations are twofold. The first, and not the least, is because the mixture of the two salts is entirely objectionable, and ought not to be used in that form by any physician understanding the therapeutic effects of the medicine. Dr. J. F. Churchill, the initiator of the treatment with hypophosphites, the greatest authority in this case, has some- times alternated the two different salts with the same patient, according to the physiologic or pathologic symptoms produced by either, but he never mixed them, knowing too well that in many cases one or the other was contra-indicated. The second reason is that the hypophosphite salts, as sold, Dr. De Bremon-Phthisis are always impure, and require careful chemical treatment to deprive them of dangerous impurities, which so interfere with their therapeutic action as to always modify, and frequently abort the result for which they are given. Another suggestion that I would offer to my professional brethren is that the doses that are recommended for general use are too large, and sometimes enormous, surpassing three times the doses that Churchill has given as a general limit to obtain good therapeutic effects. My own experience of more than twenty years in the treat- ment of the disease corresponds entirely with his directions. It is true that at the beginning large doses will work mar- vels, but it will soon be shown that they aggravate in place of curing, and in the end will do more harm than good. The scope of this little work does not permit me to give cases that I have treated and cured or benefited by the syrups of hypo- phosphites ; but later, as an appendix to it, and when the time will permit me, I will give a detailed record of more than one hundred and fifty cases that have been under my observation ; but never have I, nor will Z, use a combination of the two salts. In my opinion, and in my experience, they are more injurious than beneficial. Make a careful observation of R; W. Gardner's syrups, em- ployed separately and according to the case in your hands, using the modified doses suggested, and you will soon be convinced that, while a priori, the effects may not be so brilliant, yet the attainment of the end you have in view will be, at least, sure." In a personal communication to the writer, Dr. De Bremon further remarks:- " Having had a very long experience in the use of the Hypophosphites, and having carefully watched their effects in the treatment of phthisis, I take the liberty of giving you my views respecting the doses best adapted to the treatment of this disease. I recognize that as a chemist, you have done a great service to the medical profession. Your salts are pure ; and the elimina- 123 Dr. De Bremen-Phthisis. tion by you of all impurities, many of them dangerous, has put in our hands preparations upon which we can rely for good therapeutic effects. I consider it of great importance in this disease, that certain doses should never be exceeded. I have observed that when given in certain definite quantities per day, the results are stead- ily and permanently favorable, though somewhat slow; but when the dose is increased beyond these limits, while the imme- diate effect is frequently surprisingly favorable, the ultimate re- sult has been the production of certain pathologic symptoms, epistaxis, and frequently haemoptysis, owing to an excessive absorption of the remedy. The salts to which I wish particularly to call attention, being those which I invariably use in this disease, are the salts of Soda, and Lime. Hypophosphite of Lime is generally used only in the second and third stages of the disease. This salt produces with much ener- gy the undesirable results I have alluded to, when pushed too far. Hypophosphite of Soda is employed in the first stage of the disease ; its effects are slower than the Lime salt, but more sure when given in quantities not exceeding seven grains in twenty-four hours; but in larger quantities it will produce the same effects as the Lime salt, and instead of proving beneficial, will acceler- ate the process of softening, by its excessive activity. I would therefore discriminate, when the Lime or Soda salts are used in phthisis, between adult males, adult females, children (males and females), and infants. As your Syrups of these salts are each twenty grains in one fluid ounce, the proper doses will be approximately met by the following quantities, viz. :- Adult males, one teaspoonful, two or three times a day. Adult females, one teaspoonful, two or three times a day. Children, 7 to 15 years of age, ten to forty drops, three times a day. Infants, two drops, three times a day." J. D. Albright, M. D., Akron, Pa., reports:-39 124 39 Medical Summary. Clinical -Phthisis. 125 " Those who have given the study of the Hypophosphites the most earnest attention, concur, I believe, in the assertion that the administration of the single salts are attended with the most positive and beneficial results, and as far as pertains to clinical experience, I can assert that my experience has led me to believe likewise. I have long used the Hypophosphites of Lime, Soda and Quinia, each singly, as indicated, and I am posi- tive that the results are much superior to those of the so-called compound hypophosphites. I find that when the indicated prep- aration is given, it produces no irritation, but it is taken up along with the food and carried into the economy, there to be as- similated, and supply the waste which constitutes the first link in the chain of a morbid condition. It is in pulmonary diseases with emaciation, cough, debility, haemorrhage and the whole train of too well known symptoms of tubercular disease, that the benefits of these preparations are most apparent. It is, however, necessary that the indicated salt be given, and that a good and permanent preparation be used. The preparations which I have used, and which I consider per- fect, are those manufactured by Gardner of N. Y. They are elegant in appearance, pleasant to the taste, do not disagree with the stomach and do not in the least irritate." D. J. Parsons, M. D., Sweet Springs, Mo., Oct. 21, 1895, reports :- " I am thoroughly convinced of the great value of the single salts of the Hypophosphites, according to Churchill's method, in the treatment of phthisis, and I cannot for my life see why it is that physicians generally do not adopt it. I feel certain, with my limited experience, that the single salt method will cure consumption, if given early ; and I further believe that it will cure in the second stage. I feel that the information received from Mr. Gardner's literature has enabled me to save several from confirmed phthisis. ' ' P. J. Bailey, M. D., Dawson, Ky., reports:- " I have been using Gardner's syrup of Hypophosphite of Clinical-Phthisis. 126 Soda and syrup of Hypophosphite of Lime in cases of phthisis pul- nionalis with success. I have at this time five cases of phthisis pulmonalis, all improving. Case i.-Is about well; he is going about attending to his ordinary duties. This was a case of four years' duration. He is well except a little cough in the morning and a slight shortness of breath when walking up hill. Previous to treatment he had five or six haemorrhages from the lungs, and has distinct cavity in right lung. I have never given more than seven and a half grains per day, and but one salt at a time, and have never produced pathologic effects as yet. I consider your syrups, used according to Churchill's meth- ods, the only treatment offering the slightest hope of success in consumption. I shall use your syrups and no others unless they fail me in the future, for I have nothing to fall back upon that would afford even temporary relief. I congratulate you upon the high char- acter and chemical purity of your preparations." Walter M. Darnell, M. D., Belton, Texas, reports:- " I have used three bottles of Gardner's syrup of Hypophos- phite of Soda in a case (phthisis) and am glad to report steady im- provement under its use, though it has not been used long enough to say with certainty what amount of benefit will finally be de- rived. I have used three bottles of syrup of Hypophosphite of Time in an old chronic case in my practice, and I must say with the most flattering result, the patient having gained fifteen pounds in weight in ninety days." J. T. Wrightson, M. D., Newark, N. J., reports:- " Case of pulmonary tuberculosis. Father died (tubercu- losis) at 35 years. Four children died before 17 years of age. This patient, girl, last child, came to me at 16 years of age. Had all the symptoms of phthisis, none missing. Her stomach in irritable condition. Prescribed Gardner's preparation of Hy- pophosphites, which was borne readily by the stomach, and patient immediately commenced to improve. Clinical-Phthisis. She eventually recovered completely, married, moved to Con- necticut, and now has a family," Joseph M. Patton, M, D., Prof. Internal Medicine, Chicago Polyclinic, in a paper upon ''Treatment of Pulmonary Tuber- culosis, ' ' says:-40 ''In my own practice, both public and private, I have for years past treated a number of cases with Hypophosphites in the form of a syrup of whichever salt was indicated; I prefer Gardner's syrup as being the most stable on the market. This must not be confounded with the combined Hypophosphites. The latter preparation I used for several years in a large number of cases and became firmly convinced of the truth of Churchill's teaching, that the compound syrup of Hypophosphites is dis- tinctly injurious to phthisical patients. The Hypophosphite of Soda is generally the most useful, and is given in apyretic cases where there is not much expecto- ration. The quinia salt is used temporarily when the temperature is over ioo° Fahrenheit, and the lime salt where there is too free expectoration, six or seven grains daily being the maximum dose." A. U. Bvarts, M. D., La Porte City, Iowa, reports : - " I am satisfied that through Gardner's Syrups of the Single Hypophosphites alone, I have saved one consumptive's life, and probably two. The positive case was the worst one,-in the third stage of phthisis. Patient confined to bed-fever, cough, night sweats, and haemorrhage that presaged immediate dissolution. Right lung cavernous, and almost wholly hepatized-left lung partially implicated. After a thorough examination, I gave the patient about three weeks to live. Put patient permanently upon Gardner's Syrup Hypophosphite Lime. Improved slowly but surely for a year and a half; occasionally patient has return of bad symptoms. On an average of once in three months for two years, this case, a woman, has had a formation and rupture of pelvic tumor. 127 40 Read before the Chicago Medical Society, May, 1893. Clinical - Phthisis. 128 Have had a number of other cases, first and second stages, and have been obliged to prescribe different makes of the syrups, and have found disappointment from their use. To be brief, I will say I look for mathematical precision when I use Gardner's Syrups of Soda or Lime. I get better re- sults in treatment since following Dr. Churchill's mode." Churchill's Method Applied with Success in Forty-five Cases of Phthisis Pulmonalis. From The Journal of the American Medical Association, Feb. 27, 1897. BY T. BLANK. M. D., ST. LOUIS, MO. Too little attention has been paid to " Churchill's method " of treating consumption, although it is still the best method, and if well studied and rightfully applied, will result in a cure in a great many cases. We cannot expect much good from this method at the last moment ; it must be applied early. In the in- cipient stage, and in the beginuingof the cavernous stage, ninety cases out of a hundred can be cured by the Churchill method. But the physician in order to succeed, must study it closely. He must be a good observer, otherwise he will fail or do harm. The Churchill method depends upon the theory of phos- pholigy. If there is a decrease of molecular or intra organic combustion, due to a want of the phosphide (oxidizable phos- phorus) element in the bioplast (or bioplasmic principle as Churchill calls it), then the tissue breaks down and the soil for the tubercle bacilli is prepared. Now we come to the point: What is the condition that fa- vors a foot-hold of the tubercle bacillus ? It is the deficiency of the phosphide (oxidizable phosphorus) element. If this element is not present in sufficient quantity in the tissue, the oxygen we inhale with the air is not utilized to the fullest extent, owing to a lack of oxidizable phosphorus in the organism, which acting by its chemical affinity, is necessary to secure its combination with the proximate principles ; and instead of normal bioplasmic Dr. Blank - Phthisis. 129 material being produced, a broken down tissue is substituted- the soil for the tubercle bacilli. The Churchill method supplies this oxidizable phosphorus in the form of chemically pure hypo- phosphites. It is really astonishing to see patients improve all around, and gaining from one to two pounds per week, by supplying the long needed oxidizable phosphorus-a regular God send, as a drink of water would be to a dying man in the desert. But the improvement consists not only in the gain of weight, cessation of cough, night-sweats, fever, etc., but in the lungs, a process is taking place most interestingly. Dead cells, broken down tissue, millions of tubercle bacilli, are expectorated ; while under the influence of the hypophosphites, new normal bioplas- mic tissue is formed ; tissue which will resist the bacilli, until the last one is expectorated. I have made repeated microscopical examinations of cases, discharged as cured, and could not find a single tubercle bacillus -they were gone, though plentiful at the beginning of the treat- ment. Churchill used the hypophosphites of soda, lime, and qui- nine. He never combined any of these. He gave but one salt at a time, because each salt has a different action, for instance, in the incipient stage, and in the second stage, where the expectora- tion is tight and cough troublesome, the hypophosphite of soda is indicated, because it favors expectoration, and clears the lung of dead tissue-but watch it closely ; if expectoration is too free that means too rapid softening of the tubercular deposit, and then the lime salt must be given. The lime salt reduces expec- toration and softening, as in case No. 23, where the expectora- tion was reduced from one and a half pints per day, to only a few tablespoonfuls in measure. The action of these different salts is so distinct, that it vexes me each time I see an advertisement of syrup of hypophosphites of soda and lime together, claiming to be according to Churchill. Such statements are false ; Churchill never used these salts in combination in tuberculosis pulmonalis. Dr. Blank-Phthisis. 130 The hypophosphite of quinine is given in the initial treat- ment of far advanced cases, and later on, the soda or lime salt is given according to indications. Why is it that the brilliant results obtained by Dr. J. F. Churchill in the Parisian Hospitals are not generally obtained ? This is due to several causes : Firstly, most of the commercial hypophosphites are not chem- ically pure, therefore valueless. Secondly, if the chemically pure hypophosphite salt is not incorporated with pure syrup immediately after its manufacture, it will be rapidly injured by age. Thirdly, many physicians have given a combination of dif- ferent hypophosphite salts believing that they apply the Churchill method ; this is the most frequent cause of failure. Of the forty-five cases I have treated within the past three years, I have given, following, the history of the most import- ant, frequently giving only a synopsis of those, the history of which had been similar, or identical with those published more in detail. I will say, that the wonderful success which has resulted from my use of the Churchill method in this disease, has so con- vinced me of its worth, that I shall continue its use until, as I trust, we shall be able to cure ninety-nine cases out of the hundred. Before closing, let me express my sincere gratitude to R. W. Gardner, New York, who does so much to spread the teachings of Churchill. Case I.-Mr. John W., East St. Louis, Ill. Date of con- sultation, June 18, 1893. Age, 20 years. History.-For about a year, had complained of a cough, dry and hacking in the beginning ; expectorated blood some months ago; lost considerably in weight within the last few months ; there have been night-sweats, but not severe ; appetite failing. Examination of chest: Infra-clavicular region on the left side sunken ; inspiration in this region, rough, with dry rales; expiration blowing (bottle sound) ; on right side, sam-a condition ; percussion : cracked pot sound. Dr. Blank-Phthisis. 131 Microscopic examination of sputum (made June 23d.) Re- sult, tubercle bacillus. Treatment.-Syrup Hypophosphite of Soda, (Gardner.) Dose half teaspoonful, t. i. d., after meals. Report, July 1st, 1893. Patient feels stronger already. Ex- pectoration not much increased, continued Syrup of Soda Hypo- phosphite same doses, gave eight ounce bottle. Report, Sept. 2d, 1893. Patient has been in Kansas City ; accepted work there, as he felt strong enough to do so. Has gained in weight; appetite good during the last two weeks of August, cough has disappeared entirely. But now there is some cough again ; continued Syrup of Soda Hypophosphite in half- teaspoonful doses, t. i. d. Report, Sept. 9th, 1893. Patient still gaining in weight; sleeps better than ever before ; no night-sweats ; appetite good ; very little cough; continued Syrup of Soda Hypophosphite, twenty drops, t. i. d. Report, Oct. 3d, 1893. Patient is doing nicely ; still gaining weight; total gain since the beginning of treatment, 25 pounds; no cough nor expectoration ; discontinued the Syrup Soda Hopo- phosphite. Report, Dec. 12th, 1893. Patient at office again ; intends to go West to accept work ; as a matter of precaution he wants to take a bottle of medicine along, but as he has felt so well since October he thinks he will not have use for it. Remarks. I have not seen the patient since the date of last report, but from patients whom he has sent I have heard that he came back again from the West, and is living in East St. Louis again, in good health. The last indirect report I re- ceived about him, was in 1894. The exact date I have not recorded. Cases Nos. 2 to 9, inclusive, were so similar in their general characteristics, and history, that I have not considered it neces- sary to give a detailed account of them. They were all in their general features, duplicates of Case No. 1. The tubercle bacil- lus was found in every case at the beginning of treatment, in- Dr. Blank-Phthisis. 132 deed, I do not diagnose a case as consumption, until I find the bacillus present. Case 10.-Miss A. L. B. Age 21 years. Date of consulta- tion, June 5th, 1894. History.-Since February, this year, the patient has been suffering with amenorrhoea ; lost rapidly in weight, six pounds in as many weeks ; all last winter patient suffered with cough ; dry at the beginning ; now there is expectoration with little cough effort, expectorates small lumps, as she expresses it. Examination of chest. Left and right supra-clavicular re- gion affected ; on both sides, expiration blowing (bottle sound); inspiration rough, rolling, with moist rales ; right and left infra- clavicular regions show dullness on percussion ; inspiration in these regions, rough, with dry rales (but very fine.) Microscopic examination of sputum, with the result of find- ing tubercle bacillus. Treatment.-June 7th, 1894. Syrup of Hypophosphite of Soda (Gardner), in half-teaspoonful doses, t.i.d., after meals. Report, June 18th, 1894. Expectoration slightly increased ; thinks she feels somewhat stronger, but not much ; decreased the dose of Syrup Soda Hypophosphite to twenty drops, t.i.d. Report June 28th, 1894. Patient feels stronger; sleepswell; appetite is increasing; coughs very little; the sputum is brought up with very little effort ; she no longer notices lumps in the expectoration ; continued Syrup Soda Hypophosphite, in same dose. Report, July 15th, 1894. Has gained one pound in weight; feels strong ; appetite good ; hardly any cough ; expectoration just as I want it; continued Syrup Soda Hypophosphite, in twenty drop doses, t.i.d. Report, August 7th, 1894. Patient looks well, has gained another pound since the last visit; there is a little lassitude ; dis- continued Syrup Soda Hypophosphite on account of this. Report, August 27th, 1894. The lassitude has not left her ; closer examination shows that she had a chill about a week ago ; fever followed the chill; some sweat after the fever had left her; Dr. Blank-Phthisis. 133 since then she felt chilly and feverish, off and on ; headache ; sleepy during the day ; loss of energy ; slight cough again. Diag- nosis, malaria ; gave quinine in solution. Report, Sept. 5th, 1894. Feels better; has not been fever- ish the last few days ; feels no longer sleepy during the day ; no headache ; continued quinine in smaller doses, added Fowler's solution. Report, Sept. 15th, 1894. There are no longer symptoms of malaria ; coughs very seldom; hardly any expectoration; dis- continued all medication ; gave order to report again in, two or three weeks. Report, Oct. 8th, 1894. Expectoration a little tight; gave Syrup Hypophosphite Soda in twenty drop doses, t. i. d. Report, Oct. 20th, 1894. Expectoration no longer tight; appetite fair ; no symptoms of malaria have reappeared ; contin- ued Syrup Hypophosphite Soda, in twenty drop doses, t. i. d. gave order to discontinue medicine for a week, if expectoration should get too free. Report, Nov. 25th, 1894. Patient has regulated the medi- cine according to the condition of the expectoration; there is now neither cough nor expectoration; has gained four pounds since the last time she was weighed; Syrup Hypophosphite of Soda, six fl. ounces, dose, twenty drops, t. i. d., gave order to commence with medicine in about a week from now ; take it for one week every day ; then every other day. Report, Feb. 23d, 1895. Patient has not taken any medi- cine for about two months ; has some of it on hand yet; no cough nor expectoration ; feels better than for years. Remarks. Patient is married. I treated her husband in the latter part of November, 1895, f°r indigestion, etc., says that his wife has not been sick since she saw me last. " If he only had her stomach he would not suffer with indigestion," was one of his remarks. I have not heard of the family since then. Cases II to 23, inclusive, are all similar to case No. 1, and are not reported in detail. The tubercle bacillus was found by microscopical examination in every one of these cases, at the Dr. Blank-Phthisis. 134 commencement of the treatment. The examination for the bacillus was not regularly made at the close of the treatment, as it would involve some expense to the patient, and it seemed un- necessary, as they were feeling well. One of the cases where the bacillus was plentiful at the be- ginning of the treatment, showed a few bacilli after some months treatment. Case 23. Mr. J. B. W., C., Mo. History.-Patient has had a cough for about two years, dry and hacking in the beginning ; later it commenced to get loose ; and patient coughed up lumps of a greenish-yellow color ; soon commenced to lose flesh ; for the last six months, severe night-sweats; shortness of breath for about a year; feels very weak ; coughed up blood, off and on, within the last year ; had a severe haemorrhage eight mouths ago; the last haemorrhage, fourteen days ago ; cough very troublesome during the night; no appetite ; fever in the evening. Examination of the Tungs : Both apices affected. On left side, infra-clavicular region, a large cavity; blowing hollow sound on in- and expiration ; cracked pot sound on percussion, very distinct; the tubercular process has extended to the pleura, and the result is a very painful " tubercular pleurisy." Microscopical examination of sputum,-tubercle bacilli. Treatment.-June 5, 1894. Syrup of Hypophosphite of Soda (Gardner), in half-teaspoonful doses, t. i. d., after meals. Report, June 15, 1894. Patient's appetite a great deal bet- ter, feels stronger and better all around ; sleeps better too ; has coughed no blood ; those severe and painful pleuritic pains have disappeared entirely, and that is the reason, as patient thinks, that he sleeps so nicely now ; expectoration amounts to about a half-pint during twenty-four hours. Treatment.-Gave, this time, Syrup of Hypophosphite of Rime (Gardner), dose, half-teaspoonful, t. i. d., after meals. Report, June 25, 1894. Feels twice as strong as he did at the last call; appetite very good ; sleeps well ; expectoration re- duced from half a pint to about two tablespoonfuls in twenty- Dr. Blank-Phthisis. four hours ; patient is certain that it is not more ; those pleuritic pains have not re-appeared, which patient seems to appreciate more than all the other improvements. Treatment.-Syrup Hypophosphite of Lime, half teaspoon- ful, t. i, d., after meals. Report, July 5, 1894. Patient has been taking medicine just thirty days; feels well and strong; sleeps well and. appetite is fine ; has gained three pounds since he came under treatment ; expectoration gets a little too dry, therefore changed the medi- cine. Treatment.-Syrup Hypophosphite Soda, (Gardner). Dose, twenty drops, t. i. d., after meals. Report, August 15, 1894. Has been without medicine about four weeks ; felt well and strong all that time ; in fact he felt so well that he considered wood-sawing in his yard, the best thing to kill time ; a slight hsemorrhage followed, after ten minutes' work. Expectoration about four tablespoonfuls again ; changed medicine immediately. Treatment.-Syrup Hypophosphite Lime(Gardner). Dose, twenty drops, t. i. d., after meals. Report, August 25th, 1894. Expectoration amounts to about two tablespoonfuls during 24 hours. Treatment.-Syrup Hypophosphite Lime, in small doses, continued. Report, Sept. 15th, 1894. Patient has gained four pounds in addition to the three pounds gained up to July 30 ; expectora- tion about one and a half tablespoonfuls during 24 hours. Treatment.-Syrup Hypophosphite Lime, twenty drops, three times, every other day. Report, Sept. 30th, 1894. Patient is doing nicely. Treatment.-Syrup Hypophosphite Lime, same doses,every other day. Reports up to June, 1895, a year after commencement of treatment, are so monotonous, that I leave them out. Report, July 15th, 1895. Patient at office again ; will leave 135 Dr. Blank-Phthisis. 136 for Colorado in a few days, and wants two large bottles of medi- cine ; gave him Syrup Hypophosphite Soda, 12 oz. bottle, and Syrup Hypophosphite Lime, 12 oz. bottle. Being under treat- ment so long, he knows exactly when to take each, according to amount of expectoration. Received a letter about a month later. Therein patient states that he felt fine, and has the greater part of the medicine on hand. Through his uncle I heard that he got careless on account of feeling so strong and well, and exposed himself to unnecessary risks, and had, in the beginning of 1896, a relapse. He did not come under my treatment again, why, I know not. He died a few months after the relapse. Cases Nos. 24 and 25 are so similar to others given that they are omitted. Case No. 26.-Miss W. J. A., age 24. Date of consultation, July 15th, 1894. History.-For four years patient has suffered with cough, which was dry and hacking during the first year. Had severe night-sweats last winter ; lost in weight, especially within the last few months; had also a haemorrhage last fall ; feels very tired, weak, and worn out; fever in the afternoon and towards evening; headache quite frequently ; glands of the neck en- larged ; shortness of breath ; weight, no pounds. Examination of lungs. On left side, infra-clavicular region, a circumscribed catarrhal area ; on the right side, infra-clavicu- lar region, a large cavity. Microscopical examination of sputum-tubercle bacilli in great numbers. Treatment.-July 16th, 1894. Syrup Hypophosphite of Soda (Gardner). Dose, half teaspoonful, t. i. d. after meals. Report July 23d, 1894. Patient looks better ; on some days she felt really well; there is fever every evening, without chill preceding ; but about two, and sometimes three times a week, she gets a severe chill and a higher fever than usual fol- lows ; there is no doubt that we have to do with two kinds of fever ; one a " hectic" and the other a " malarial fever." She Dr. Blank-Phthisis. 137 feels also an aching in the joints, bones, and muscles before the malarial fever appears. Treatment.-Gave quinine in solution ; discontinued Syrup Hypophosphite Soda. Report, July 26th, 1894. Patient feels a great deal better after having taken quinine mixture. Treatment.-Continued quinine mixture, to be taken every other day. On the days between, continued Syrup Hypophos- phite of Soda in half-teaspoonful doses, t. i. d., after meals. Report, August 7th, 1894. Feels well, and stronger than before ; long walks no longer exhaust her ; during the first few days the cough is more frequent and somewhat dry. Treatment.-Increased the dose of Syrup Hypophosphite Soda to 40 drops, t. i. d., after meals. Report, August 14th, 1894. Patient feels stronger than at the last visit; cough is still very troublesome; expectoration amounts to about four tablespoonfuls during twenty-four hours. Treatment.-Changed to Syrup Hypophosphite Lime (Gardner), twenty drops, t. i. d., after meals. Report, Sept. 1st, 1894. Patient has been without medi- cine for ten days ; during all that time she felt well; cough and expectoration diminished ; her strength is not quite as good as when she is under the influence of medicine, but nevertheless she feels ten per cent, stronger than eight weeks ago. Treatment.-Syrup Soda Hypophosphite, (Gardner,) in half-teaspoonful doses, t. i. d. after meals. Report, Sept. 10th, 1894. Feels stronger since she has taken the medicine ; cough very moderate and not troublesome. Treatment.-Continued Syrup Hypophosphite Soda, same doses. Report, Sept. 22d, 1894. Patient feels well, expectorates very little during the day ; only in the morning, and that does not amount to much; gained five and one-quarter pounds since the beginning of treatment; present weight, 115X pounds. Patient lost in weight during the first few weeks; my books give no record of this, but I remember the case well. Dr. Shoemaker-Phthisis. 138 Treatment.-Syrup Hypophosphite Soda, half-teaspoonful, t. i. d., after meals. Report, Oct. 24th, 1894. Has been doing nicely during all that time; during the last few days she complains of pleuritic pains ; hardly any .cough ; has gained two pounds more ; present weight 117X pounds. Treatment.-Syrup Hypophosphite Soda, and mustard plaster to the chest. It would make the report too lengthy to continue the record. Patient took the Hypophosphites steadily up to August, 1895, that is, a little over a year, counting from the day of con- sultation. From August, 1895, she took the Hypophosphites only occasionally. During the year 1896, she called several times at my office, feeling generally well, and working every day. The least little cough, or loss of strength, was always promptly attacked with a bottle of Syrup of Hypophosphite, and the bat- tle ground was ours in a day or two. It was a hopeless case of four years standing, with a large cavity already formed, as it came under my observation. As I saw her last, I could not help thinking about "then" and " now." The cases Nos. 27 to 45, inclusive, were similar in their gen- eral features to case No. 1, and it would be tiresome to give the histories of them in detail. The cases I have outlined are fairly typical, and my favorable experience in the past, is now continually being repeated, as new cases come under my care; all progressing well, and may form the subject of another contribution in the future. There can be no uncertainty concerning the diagnosis ; every case was established beyond a doubt by the detection of the tubercle bacillus. 1607 Franklin Avenue, St. Louis, Dec. 15TH, 1896. Prof. J. V. Shoemaker, Philadelphia, says:- ' ' The hypophosphites have been largely used and extolled by Dr. Churchill, in the treatment of pulmonary consumption, Wilson-Love-Phthisis. 139 especially the alkaline hypophosphites,* which should be per- fectly pure, like those of R. W. Gardner, of New York."41 J. C. Willson, M. D., Morley, N. Y., writes:- " I must say that I am greatly pleased with results obtained from a number of cases of phthisis with Gardner's Syrup of Hy- pophosphite of Soda and the Syrup of Hypophosphite of Lime. Several cases of phthisis in first stage have come under my ob- servation in the past few months, and in every case there has been no failure as far as I could learn ; and, at any rate, there was so great improvement at once, that most of them went from my care apparently cured." I. N. Love, M. D., New York City, in an editorial article remarks :-4 2 "The medical profession is indeed under great obligations to Churchill, for there can be no question that his ideas have done much towards successfully battling against tuberculosis and that condition which by name was made to cover so much and in reality express so little, namely, struma, the so-called scrofula, which we now know was but another name for the many forms of tubercular expression. How many children were permitted during their period of growth and development, to suffer with so-called scrofulous glands, 'running sores,' that the old time doctor thought should not be permitted to heal for fear that they would break out somewhere else ? We know now that they were simply suppurating tubercular masses in the majority of instan- ces, and that they should have been promptly removed by the knife, if not dissipated by internal medication. The remedies just referred to, by the way, will do more in the direction of up- building the patient-giving him the power, as it were, to absorb and scatter these aggregated disturbances-than all others. To no manufacturer and pharmacist in America is the medical profes- sion under more pronounced obligation for good work done in catering to its needs than to Mr. R. W. Gardner, the chemist, of * See note f on page 89. 41 " Materia Medica, Pharmacology and Therapeutics." Shoemaker, vol. 2. page 812, 1891. 42 Medical Mirror, June, 1897. Connally-Faulkner-Phthisis. 140 New York City, especially in carrying out Churchill's ideas in giving us an ideal form of Hypophosphites and in the perfection of Syrup of Hydriodic Acid. "Mr. Gardner's Syrups of Hypophosphites and Syrup of Hydriodic Acid are beautiful preparations, readily received by the most delicate stomach and promptly assimilated and appro- priated. Their effect in all administrations is so prompt as to be almost phenomenal. "The Syrups are attractive in form, potent and permanent. As practitioners, we should see that the medicines are furnished to our patients in original packages in these days of substitution. A continued daily use of Mr. Gardner's Hypophosphites and Hydriodic Acid in my practice for more than ten years, certainly justifies the fullest confidence.'' Dr. G. R. Connally, Shannon, Miss., May 10th, 1900, writes: ' ' I am so much pleased with your Syrups of Single Hypophos- phites that I now prescribe them in preference to all others. ' ' Richard B. Faulkner, M. D., Pittsburgh, Pa., in a paper, "Clinical Notes upon Single Hypophosphite Medication,'' Feb. nth, 1901, says : "I have used Gardner's Syrup of Hypophos- phite of Soda, and Syrup of Hypophosphite of Lime in preference to all others for the past twelve years, or more ; I have used them singly, exactly in the manner indicated by Dr. Churchill; they cause improvement in digestion, increase in bodily weight, and check destructive metamorphosis. I have used the Soda Syrup hundreds of times in the early stages of phthisis with prompt effect in the relief of dry, hacking cough, and rapid improvement in the nutrition of the patient. I use the Soda Syrup habitually in the viscid stage of acute bronchitis, and make it almost a base for all other treatment in chronic bronchitis, because of its pow- erful influence upon the nerve centres, and consequent control of congested and debilitated mucosa ; also in asthma, and in em- physema. Nervous Diseases.-The late William F. Hutchinson, M. D., Providence, R. I., in a paper on " Nerve Feeding," strongly ad- INDICATIONS IN OTHER CONDITIONS. Nervous Diseases-Anaemia. 141 vocates the use of Gardner's Syrups of the Hypophosphites. He says :-" The quality of stability I have found more to be depended upon with Gardner's Syrups of the Hypophosphites, than with any other, and am so contented with results obtained with his goods, that I use no other. They are palatable, effic- ient, and reasonable in price. To my colleagues, who are not es- pecially familiar with the action of Hypophosphites in nervous diseases, I heartily recommend them."43 It would seem scarcely necessary to remind the profession of the inestimable advantage of the hypophosphites in all conditions where the nervous force is deficient, assimilation poor, and the patient suffering from a low state of vitality. No remedy so quickly restores the patient, in such condi- tions, as the hypophosphite. If in pregnancy, the Syrup of Lime is the salt indicated ; also if ossification is defective. In all these conditions the stimulating power of oxidizable phosphorus in this form is almost immediate in its action, in- creasing nervous force, stimulating the appetite, restoring assim- ilation, and by its haematogenic action, restoring the blood to its normal state. Anaemia.-In this condition it is not always necessary to administer iron ; the hypophosphite of Soda or Lime, acting upon the functions generally and restoring the assimilative power, is in some cases sufficient, of itself, as iron is obtained from the food in adequate quantity for the needs of the system. In other instances where the condition is chronic and obstinate, the Syrup of the Hypophosphite of Iron will act like a charm. Instances frequently occur where the Syrup of Hypophosphite of Manganese is especially useful in these cases. As both of these preparations are in their best chemical form for active haematinic action, the first being in the ferrous, and the latter in the manganous degree of oxidation, they are espe- cially useful in these conditions. 43 " New England Med. Monthly," December, 1892. Osteo-Myelitis-Dentition. 142 Osteo-Myelitis.-In this and kindred diseases, the hypo- phosphite of Lime furnishes material in the best possible form for the reconstruction of the osseous system. It is far superior to the phosphate of Lime, as the hypophosphite is elaborated in the organism during its subsequent oxidation, in contact with or- ganic elements, in the natural method, and appropriated as pre- pared, while the phosphate undergoes no such elaboration, being incapable of chemic change. Of course, if the disease has pro- gressed so far as to necessitate an operation, the remedy will not prevent this necessity, but in the incipient stages, or where there exists a tendency to the disease, it will prevent its development. After operations, it is the most valuable remedy that can be ad- ministered, as it rapidly facilitates the reconstruction of the bone. Dr. Lewis G. Pedigo,44 Shawsville, Va., pays a high tribute to the efficacy of Gardner's Syrup of Hypophosphite of Lime in the sub-acute and chronic inflammations occurring in the bony and periosteal tissues of scrofulous or badly nourished patients, as a result of a blow or injury, which usually result in hip-joint, Pott's disease, or some grave lesion of this character. He gives a history of a case of this kind, with complete recovery, where from the unfavorable constitutional state and family history of the patient, the prognosis was bad. Defective Dentition.-Where infants suffer from difficult or retarted dentition, are emaciated, and are threatened or are already attacked with convulsions, they have been relieved in a few days, sometimes with the first dose, and have been perma- nently cured by a few doses of Syrup of Hypophosphite of Lime. All the symptoms have been swept away at once. Q. C. Smith, M. D., Austin, Texas, in a paper45 on "The Value of Hypophosphites in Building Up the Health of Delicate and Weakly Children,'' speaks very highly of the use of the Syrups of the Single Hypophosphites of Lime, or Soda. He never combines them. He has used Gardner's Syrups for many years with great satisfaction. 44 Journal American Med. Ass'n, Jan. 20, 1894. *B Texas Courierand Record of Medicine, December, 1893. Rachitis. 143 When the important action of the hypophosphite in the economy is clearly understood, it is seen that it constitutes an inorganic food, rather than a medicine, and supplies an element which often is not contained in the organic foods in sufficient quantity to supply the needs of the organism. Hence all condi- tions which result from a lack of this element and which are known under various vague and ambiguous designations, are simply consequences due to an insufficient supply, or an excessive waste of oxidizable phosphorus, which causes a starvation for oxygen, and deficient nerve force. Under this category may be mentioned nervous prostration, marasmus, general decline, and many conditions which are char- acterized by feeble vitality, defective assimilation, emaciation, and constitutional debility. Of course, similar conditions occur as a sequel to the ravages of acute diseases, and in such cases, convalescence will be very much hastened by the use of the indicated hypophosphite. Rachitis.-Amzi W. Hon. M. D., Harrodsburg, Indiana, Oct. 29, 1895, writes : - " Some time ago I had a little patient, a babe, eleven months old, emaciated, and every symptom of rachitis. The child had been allowed to eat all kinds of food for three months previous, but had not gotten any milk. I at once put it on milk alone, for food, and Syrup of Hypophosphite of Lime (Gardner). " It weighed eight pounds at the time I commenced treat- ment ; in one month it weighed twelve pounds ; in two months it weighed seventeen pounds and was well." From a paper by C. B. Boum, M. D., Providence, R. I., on "Artificial Reconstructives," we abstract:-46 " For more than a year past I have followed with interest and care, the administration of Gardner's preparations and with a single exception, to be hereafter noted, the results have been good and their administration effective. So much so indeed, that I have arrived at the conclusion that no better form of nerve food or artificial reconstructive need be sought." 46 New England Medical Monthly, Jan., 1893. Respiratory Diseases. 144 Franklin C. Woodruff, M. D., Newark, N. J., April 4th, 1901, reports : "I have used Gardner's Syrup of Hypophosphite of Lime and in two cases of Gastralgia, in small doses, with com- plete relief of the pain, and improvement in the general condition of both patients. I am thoroughly satisfied with its action." Non-Tubercular Diseases of the Respiratory Tract. Until December, 1897, when Gardner's Syr. C. P. Hypo- phosphite of Ammonium was brought to the attention of the Pro- fession, this valuable salt had not been much prescribed, and when it was used, the ordinary impure commercial salt was ex- hibited, consequently the remarkable efficacy of the pure salt was not properly appreciated. It is now, however, widely known and enthusiastically en- dorsed by all physicians who have used it. This Syrup acts as an alterative and resolvent, and stimulates the hepatic function. Hypophosphite of Ammonium is contra-indicated in phthisis, because its special eliminative action causes too rapid sloughing of the tubercular deposit. In laryngitis, pharyngitis, and catarrhal inflammations of the respiratory tract, Gardner's Syrup of Chemically Pure Hypo- phosphite of Ammonium is the most prompt and effective remedy. Acting as a powerful stimulating expectorant and resolvent, it facilitates expectoration, allays inflammatory action and acts as an analgesic upon the irritated surfaces. Its soothing action is manifested almost immediately after it is administered. It re- lieves the obstinate cough accompanying these conditions almost instantaneously. Chemical purity is an essential with this prepa- ration as well as all other Hypophosphite Syrups. F. A. Burrall, M. D., New York City, says:-"Gardner's Syrup of Hypophosphite of Ammonium is a valuable addition to our list of drugs. It is an elegant preparation, and can be used as a vehicle for cough remedies such as codeine, while alone, it allays the irrita- Respiratory Diseases. 145 tion which accompanies chronic laryngeal catarrh. A small bot- tle can be carried in the pocket, and about half a teaspoonful taken when the irritation appears, simply by putting the bottle to the mouth and allowing the small dose to blend with the saliva before it is swallowed. The relief is often immediate. I think it will be found useful for the minor coughs of children. It seems to me that one of its prominent features is that of a laryn- geal analgesic " V. T. Smith, M. D., Detroit, Mich., writes:-"Some months ago, at my request, you sent me a small quantity of your Syrup of C. P. Hypophosphite of Ammonium, which I took for the purpose of ascertaining its effect upon an obstinate cough, which I contracted four years ago, while crossing the English Channel. I had done everything for it myself without avail, and so had numerous other doctors, with no better luck. Then having read a description of your Syrup of Hypophosphite of Ammonium, I received a four ounce bottle. Before I had taken two-thirds of it, my cough had disappeared and has never re- turned' I am now prescribing it daily and it has never failed me.'' Elmer B. Eddy, M. D., Greenville, R. I. : ' ' I am using your Syrup of Chemically Pure Hypophosphite of Ammonium with the grandest results.'' Dr. C. N. Miller, San Francisco, Cal., Jan 7th, 1901, writes : ' ' I am using your Syrup C. P. Hypophosphite of Ammonium with great success in la grippe, where there is cough and conges- tion." Dr. Frederic H. Plummer, Chelsea, Mass., March 9th, 1901, writes : " I can certainly commend your Syrup C. P. Hypophos- phite of Ammonium, as I have used it liberally since you placed it on the market. ' ' I have used Gardner's Syrup of C. P. Hypophosphite of Ammonium for the past year, in cases of acute bronchitis, pneu- monia, and la grippe; it liquifies tenacious, viscid mucus, and facilitates expectoration. It seems to serve these purposes better than the chloride of ammonium. It acts promptly, does not dis- Indications of Hypophosphites. 146 turb the stomach, and its phosphorus base is an advantage over the chloride on account of its effects upon general nutrition, thereby rendering recovery a more ready accomplishment." Elbert E. Fisher, M. D., Rodney, Iowa, May 6th, 1901, re- ports : " I have used Gardner's Syrup of Hypophosphite Ammo- nium in some cases of Chronic Bronchitis with remarkably good results. I have never had anything from which I got such quick and permanent effect." S. J. Brownson, M. D., Elkins, Arkansas, May 9th, 1901, reports : " Gardner's Syrup of Hypophosphite Ammonium C.P., excels any preparation I have ever tried for cough." J. M. Abbott, M. D., Macon, Fla., June 3d, 1901, reports: " Gardner's Syrups of Hypophosphites are perfectly satisfactory; I have given them a thorough trial." J. R. Johns, M. D., Philadelphia, Pa., April 20th, 1901, re- ports : " I have used Syrup Ammonium Hypophosphite, C. P., (Gardner) in a case of Neurasthenia when the usual syrup hypophosphites U. S. P. was not well borne, and obtained good results from it." S. A. Gluck, M. D., Brooklyn, N. Y., April 20th, 1901, re- ports: " I have used Gardner's Syrup Ammonium Hypophos- phite C. P., in my Laryngeal cases; also in dry coughs and Bronchitis. In prescribing Hypophosphite preparations I always specify Gardner's because they are known to be chemically pure, and as I always get good results from these preparations, I still continue to use none but Gardner's." Action of Gardner's Single Hypophosphite Syrups. SYRUP OF CHEMICALLY PURE HYPOPHOSPHITE OF SODA. SYRUPUS SODII HYPOPHOSPHITIS (GARDNER). Strength, Twenty (20) grains in One fluid ounce. Hypophosphite of Soda is more generally indicated than any other Hypophosphite. It exercises a slight influence in favor of expectoration. Indications of Hypophosphites. 147 It almost universally agrees with the patient. If in doubt which hypophosphite is indicated the Soda salt may safely be prescribed. The most useful in instances requiring rapid assimilation of ohosphorus. This salt is usually indicated in the first stage of phthisis. When the Syrup of Lime has been used and the expectora- tion is too scanty, and it is desirable to increase it, the Soda Syrup should be substituted. SYRUP OF CHEMICALLY PURE HYPOPHOSPHITE OF LIME SYRUPUS CALCII HYPOPHOSPHITIS (GARDNER). Strength, Twenty (20) grains in One fluid ounce. Hypophosphite of Lime slightly checks expectoration. In cases when the Hypophosphite of Soda is contra-indicated this is the alternative remedy. This salt is usually indicated in the second and third stages of phthisis. Indicated in all instances of defective osseous development, as in cases of rachitis, teething children, osteo-myelitis, etc. It is a remarkable bone reconstructive as well as a tissue builder. Hither one or the other of the above Syrups are indicated in all adynamic conditions, in nervous insufficiency, in marasmus, in convalescence from severe acute diseases, as fevers, etc., as general tonics w7hen the vital powers are inadequate, in anaemia, in all instances when the function of haematosis is defective, as in boils, abscesses, etc. SYRUP OF CHEMICALLY PURE HYPOPHOSPHITE OF AMMONIUM. SYRUPUS AMMONII HYPOPHOSPHITIS (GARDNER). Strength, Sixteen (16) grains in One fluid ounce. Hypophosphite of Ammonium is a very active expectorant, alterative and resolvent, and is far better than the chloride or carbonate of Ammonium as a laryngeal and faucial stimulant, and has the additional advantage of being perfectly palatable. It stimulates the hepatic function. Indications of Hypophosphites. Indicated in laryngitis, pharyngitis, coryza, catarrh, bron- chitis, asthma, hoarseness, ordinary coughs and colds, etc. Indications the same as for Ammonium Chloride, but it is more active. Hypophosphite of Ammonium is contra-indicated in phthisis. Its special eliminative action, by over stimulation, causes a too free expectoration and sloughing of the tubercular deposit. 148 SYRUP OF C. P. HYPOPHOSPHITE OF IRON. SYRUPUS FERRI HYPOPHOSPHITIS (GARDNER). Strength, Four (4) grains in One fluid ounce. The form of Iron contained in this preparation is the Ferrous Hypophosphite. The same argument previously expressed in regard to Phos- phorus,-that it should be administered in its lowest oxidized form,-applies with great force in the assimilation of Iron. The ferrous salts, being in the primary stage of oxidation, are active metabolic agents in the economy, undergoing subsequent oxida- tion in contact with the organic constituents of the plasmic ma- terial, thus affording nature the opportunity to elaborate her own material in a natural manner. The ferrous salts, for the forego- ing reasons, are much to be preferred to the ferric salts, for active and prompt haematinic action, notwithstanding the fact that the ferric salts are at present more largely prescribed. In addition to the effect of this form of iron as a haematinic, it is, in this preparation, reinforced by the remarkable action of oxidizable phosphorus, itself the most powerful of nervous tonics. This combination is unequalled by any other form of medication, when the peculiarly valuable physiological action of these two remedies is indicated. Indicated in chlorosis, anaemia, general debility, female dis- eases, in certain nervous disturbances, and whenever a chalybeate and haematinic is required. Contra-indicated in phthisis, as it tends to produce a plethoric condition of the blood vessels, whose walls are weakened by the general emaciation caused by the disease ; this renders them prone Indications of Hypophosphites. to rupture under the influence of Iron, owing to its stimulation of haematosis. 149 SYRUP OF C. P. HYPOPHOSPHITE OF MANGANESE. SYRUPUS MANGANI HYPOPHOSPHITIS (GARDNER). Strength, Four (4) grains in One fluid ounce (of the Mangan- ous Hypophosphite). Hypophosphite of Manganese acts in the same manner as Iron, but with less energy. It has a special excitatory action upon the biliary secretion, and is peculiarly useful either alone or in conjunction with Hypo- phosphite of Quinine, in hepatic derangement, with deficient bil- iary secretion, subsequent upon prolonged residence in tropical climates, as also in cases of Anaemia and general Debility depend- ing upon the same cause. Indicated in conditions similar to those in which Iron is used, and when the latter disagrees this may be used with the same desirable results, without trouble to the patient. Contra-indicated in Phthisis for the same reasons as the Iron salt. SYRUP OF C. P. HYPOPHOSPHITE OF POTASSIUM. SYRUPUS POTASSII HYPOPHOSPHITIS (GARDNER). Strength, Sixteen (16) grains in One fluid ounce. In Chronic Bronchitis, and in the sequelae of inflammatory diseases of the respiratory organs, where there is debility de- pending upon anaemia and lowered nutrition, great benefit will frequently be derived from the use of this preparation; also in some cases of Asthma where nutrition has become greatly im- paired. Contra-indicated in Phthisis for the same reasons given under Hypophosphite of Ammonium. ELIXIR HYPOPHOSPHITE OF QUININE. ELIXIR QUININAE HYPOPHOSPHITIS (GARDNER). Strength, Eight (8) grains in One fluid ounce. Indicated when a general and nervous tonic is required. Indications of Hypophosphites. 150 Used in cases of phthisis when the disease has become far advanced, as the initial treatment, to be continued until the pa- tient can bear the Lime or the Soda salt, also in cases of malarial complications. In cases of inter-current inflammation, or other complica- tions, when the Lime or Soda are found too stimulating. To combat the rise in temperature when excessive. IODINE AND PHOSPHORUS. INDEX. Page. Action of Free Phosphorus 65, 66 Acute Inflammatory Rheumatism 3D 32, 33> 34, 37 Acute Phthisis 102, 103 Alcoholic Stimulants, Why Contra- indicated in Phthisis 81, 87 Alkaline Hypophosphites. See notej- p. 89 Iodides 13, 14, 15 irritant action of 14, 19 Amenorrhcea, Phthisis Complicat- ed with 98 Action of Hypophos- phite on 99 Ammonium Hypophosphite 144 145, 146 147, 148 Anaemia Treated by Hypophos- phites 141 Syphilitic 37, 39 Anodynes, Why Contra-indicated in Phthisis 81 Antagonism between Vitality and Phthisis 70 Arsenic, Favorable Action of Hypo- phosphite Prevented by 87 Asthma 21, 22, 23, 30 Chronic 22 Auscultation Necessity of Accuracy in 103, 104, 105 Bin-Iodide Mercury, Combined With Hydriodic Acid 36,38, 42 Blood, Change of Color, When Hy- pophosphite is administered.... 74 Page. Bronchitis 21, 30 Acute, Ammonium Hy- poplios. in 145, 146 Chronic 23, 24, 146 Calcium Hypophosphite 147 Iodide 14 Catarrh, of Bladder.. 46 Bronchial 27 Chronic Daryngeal 145 Intestinal 27 Nasal 27, 37 Pulmonary 26 Uterine 24 Carbon Di Oxide, Excretion of.... 73 Cerebral Gumma 43 Cervical Glands, Enlarged 52 Chronic Rheumatism 32, 33, 34 Churchill's Methods, Summary of 112, 113, 114 Clinical Histories Phthisis. .115 to 144 Cod Diver Oil, Effect of 87 Danger of Using... 91 Complications in Phthisis 89,95 Compound Hypophosphites, Why They Should Never be Used .... 80 Conjunctivitis 37, 51 Constipation, Chronic 44 Contra-indicated Remedies 81 Cough, Action of Hypophosphite on 99 Ammonium Hypophos- phite in 145 Croup, Spasmodic 29 Page. Cystitis. 44 Dentition, Defective 142 Diseases of Respiratory Tract.20 to 31 Dosage in Phthisis 80, 88 Dyspnoea 21, 87, 99 Eczema 37 Effect of Combinations of Hypo- phosphites 86 Epistaxis 85 Exophthalmic Goitre 49, 50, 51 Expectoration, Action of Hypo- phosphite on 99, 146, 147 Ferrous Hypophosphite 148 Iodide 14 Fever, Action of Hypophosphite on 96, 97, 98 Fibroma 47, 48, 49 Free Phosphorus, Action of. .. .65, 66 Effect of admin- istering 66 Oxidation of.... 66 Solutions of 66 Genito-Urinary Diseases... .43, 44, 45 Glandular Diseases 24, 51, 52 Goitre, Exoptlialmic 49, 50, 51 Gout 32 Haemorrhage, Caused by Iron .... 86 Haemoptysis 96 Hay Fever 21, 24, 25, 26 Hepatic Cirrhosis 52 History of Hydriodic Acid.. 16, 17, 18 Phosphorus 65 Hydriodic Acid, Antiseptic Action of,. 20 (Gardner's Syrup', Applicable when Iodides are Contra-indi- cated 19 (Gardner's Syrup), Combined with Bin-Iodide of Mercury in Syphilis 36, 38, 42 (Gardner's Syrup), Effect on Mu cous Surfaces 20, 21 Page. (Gardner's Syrup', Non-irritant Character of 19 (Gardner's Syrup', Palatability of 19 Percentage of HI 19 (Gardner's Syrup), Physiological Suitability of 19 (Gardner'sSyrup), Therapeutics of 18 to 52 inclusive Hydriodic Acid, Gaseous, Buchan- an's Formula for Aquaeous So- lution of 16 Hydriodic Acid, Gaseous, History of 16, 17, 18 Hydriodic Acid, Gaseous, Mur- doch's Formula for Aquaeous Solution of 16 Hydriodic Acid, Gaseous, Physical and Chemical Properties of 16 Hypertrophy of Prostate Gland. .. 46 Hypophosphite Ammonium 144 145, 146, 147, 148 Calcium 147 Iron 148 Lime 147 Manganese 149 Potassium 149 Quinine 149, 150 Sodium 146, 147 Hypophosphites, Action of Single Syrups of 146 to 150 Action of Impuri- ties in 78 Alkaline, see note t P- 89 Alkalies given with the 113 Antagonistic Ef- fects of Different Bases 67 as Inorganic Foods 74 Page. Hypophosphites, Causes of Failure in Use of 78 Careless Investi- gation of 66 Complex Com- binations of 66 67, 80, 86, 92 Elixirs of, Why they should not be used 80 Impure Salts of. 66 Indications for, 146 to 150 Object of Admin- istering 68 Oxidation of..,. 79 Pathologic Ef- fects of 82 Physiologic Ef- fects of 82 - Poly - Pharmic Combinations of 80 86, 92 Time to Adminis- ter 93 Why they should only be used as Syrups 79 Impurities in Hypophosphites, Ac- tion of 78 Intra-Organiv Combustion 73 Oxidation 72, 73 Introduction, Iodine 11, 12, 13 Phosphorus 63, 64 Iodide of Calcium 14 Hydrogen 15 History 16, 17 18 Iron 14 Mercury 14 Potassium 13 Sodium 14 Strontium 15 Page. Iodides, Alkaline 13, 14, 15, 19 Chemical and Therapeuti- cal Value of 13, 14, 15 Iodine Strength of... 13, *4, ....15, 19 Iodine as an Alterative.... 13 Iron, Danger of in Phthisis 86 Hypophosphite of 148 La Grippe 30, 31 Ammonium Hypophos- phite in 145 Laryngitis 21, 30, 144, 146 Phthisis complicated with ....97, 98 Lead Poisoning 46, 47 Leucorrhcea 45 Lime, Hypophosphite of 147 Iodide of. 14 Locomotor Ataxia 52 Manganese, Hypophosphite of.... 149 Mercurous Iodide 14 Mercuric Iodide 14, 15 Combined with Hydriodic Acid.36, 38, 42 Mineral Vaters in Phthisis 113 Narcotics in Phthisis 81, 92 Nervous Diseases 140, 141 Night-Sweats, Action of Hypo- phosphite on 96, 98 Opiates in Phthisis 81, 92 Osteo-Myelitis 142, 147 Ovary, Tubal Disease of 43, 45 Overdosing in Phthisis 88 Oxidation of Hypophosphites 79 Intra Organic 72, 73 Oxidizable Phosphorus 7 c Action of.. 71 As an Inor- ganic Food 74 in Milk.... 74 Oxygen in the Nascent State as a Germicide 72 Page- Phthisis 68 Acute 102, 103 Classification of by Stages 82 Clinical Matter on Bailey 125, 126 Blank 128 to 138 Connally 140 Darnell 126 De Bremen. ...11510125 Evarts 127, 128 Faulkner 140 Love 139, 140 Parsons 125 Patton 127 Shoemaker 138, 139 Wilson 139 Wrightson 126, 127 Complications in 89 Conclusions. 108,109,110, in Condition of Cure 101 Diet in 90 Dosage in 80, 88 Etiology of... .69, 70, 71, 72 Graduated Scale of Le- sions 82 Pre-tubercular Stage of.. 69 Prognosis in, when Treat- ed by Hypophosphite. 94 Summary of Churchill's Methods in 112 to 114 Pharyngitis 144 Phosphates, Differentiation be- tween Hypophosphites and 71 Phosphide Principle 71, 72 Phospholigy 74 Phosphorus, History of 65 Physiologic Action of 65, 66 Poisoning by 66 Plethora 91 Pleurisy 27, 33 Pleuritic Exudations 21 Page. Pneumonia 21, 27, 28, 29 Acute 28, 37 Ammonium Hypophos- phite in 145 Croupous 44 Dosage in 28, 29 Poisoning by Lead, Mercury or Ar- senic 46 Potassium, Hypophosphite of 149 Iodide 13 Irritant Action of 13 Toxic Effects of. 13 Precautions in Using Hypophos- phites 90, 91 Prostate Gland, Hypertrophy of... 46 Pyelitis 44 Quinine, Hypophosphite of... 149, 150 Rachitis, Hypophosphites in Treat- ment of 143, 147 Relapse, in Phthisis 106 Results Obtained From Hypophosphite in 106, 107, 108 Renal Torpor ■ 44 Respiratory Tract, Diseases of, 20 to 31, 144 to 146 Non Tubercu- lar Diseases of 144, 145, 146 Rheumatism, Acute Inflammatory 3i, 32, 33, 34, 37 Chronic 24,31, 33 Dose in 32, 33 Scrofula 51 Skin Diseases 21 Sodium, Hypophosphite of... 146, 147 Iodide 14 Spasmodic Croup 29 Stimulants, Why Contra-indicated in Phthisis 81, 87 Strontium Iodide 15 Struma 40, 41 Page. Summary of Churchill's methods 112, 113, 114 Syphilis.. 19, 34, 35, 36, 37, 38, 39, 40 • •• 4b 42, 43 of Nervous System 35 of Spinal Cord 35 Syphilitic Anaemia 37, 39 Therapeutics of Gardner's Syr. Hy- driodic Acid 18 to 52 Tissue Oxidation 27 Page. Tuberculization, After Acute Dis- eases 76 Influence of Mo- lecular Activity on 75 in Children . ... 75 Uric Acid Diathesis 44 Venous Blood, Change of Color of. 74 Red Color of, in Phthisis 76 Vomiting in Phthisis 96, 98 S'pwtal Notin' to the Mebtral ^rnfrsBton. Gardner's - Special PharinaceUtical Preparations are designed only for physicians' prescriptions. Many physicians desire to have original bottles of our preparations dispensed, in order to prevent sub- stitution- Hn objection to this has always been, that the patient RneW what rernedy had been prescribed for hirn, as the label on the bottle described the preparation- To obviate this objection, We ha^e been putting Up our products, since September, 1900, in the following inanner: The outside wrapper has our label, with dose, strength, etc. There is also a sinall label in red, reading as follows: Tn Dimriwictq •J^d lu 1 1(q1111uU1uIu • Ind°placeeyourPoXn Prescription Label on the bottle, leaving the Strip Label over the cork and Monogram Seal, intact. TL© oqly label we LaVe or) tLe bottle itself, is a small strip label bearing tLe Latin name of tLe prepara- tion • for example- SYR. AC1DI HYDR10DICI (GARDNER) and a strip label and rnonograin seal oyer the corK, bearing th© facsimile of the iRanufacturer's signature, Which cannot be removed Without showing that th© package has been tampered With, thus ensuring to th© physician th© dispensing of exactly what he has prescribed. Th© plan is best shown in the following cuts:- Gardner's Syrup of Hydriodic Reid is put Up in 4 Oz., 8 Oz. and 16 Oz. Bottles. Gardner's Hypophosphite Preparations are put Up in 8 Oz and 16 Oz. Bottles. List of Publications by R. W. Gardner, Now in Print, Which will be Mailed to Physicians Only, upon Request. Hydriodic Acid and Hypophosphites, 1899, I6th Edition. 243 pages. Bound in Cloth. This includes all matter con- tained in the Fifteen previous Editions, covering the Chem- istry and Therapeutics of Syrup of Hydriodic Acid and also Hypophosphites, Churchill's Theory and Treatment of Tuberculosis, together with copious Clinical Notes of Treat- ment by eminent professional men. Assimilation of Phosphorus, IQOO. A resume of Churchill's Theory of the Etiology of Phthisis and its treatment. Internal Administration of Iodine, 1900. A Physiological and Therapeutical Study of this Subject. Why Hydriodic Acid is Superior to All Other Forms of Iodine for Internal Use, 1900. A Comparative Study of the Therapeutical Value of the Iodides, including a Tabulated Statement of their Relative Iodine Strength, with the Rationale of their action. Hydrogen, Iodide. Syrup Hydriodic Acid, 19OI. Hypo-Quinidol (Gardner), 1902. Describing a new form of Quinine, superior to the sulphate as a tonic, Anti-periodic and Haematogenic, producing no Cinchonism, Head Symptoms, nor Toxic Action on the Blood, and containing a large collection of Reports from Hospitals and other sources upon the actual results obtained from Hypo-Quinidol in Malarial and other diseases, and Microscopical observations demonstrating its effect in increasing Haemoglobin and destroying the plasinodium malaria. Special Therapeutic Notes on Syrup Hydriodic Acid (Gardner), 1902. Subjects: Syphilis, Goitre, Struma, Bronchitis, Bronchial Asthma, Acute and Chronic Rheumatism, Gout, Grippe, Fibroma, Poisoning by Lead, Arsenic or Mercury, Suppur- ative and Subsequent Stages of Small Pox and Pneumonia Historical Sketch of the First Use of Hypophosphites in Medicine (Gardner), 1902. A careful statement of the reasons why they fail to fulfill the claims Dr. Churchill makes for them.