WFA C563d 1860 gfgjgj LEAHY, r.oiikscller, 5th &*■*>.:-u, PlMitda. Price &5 Cents. <> \ TE'EATiSE ON THE I M jVI E D I .A. T K CAU8 I<] AND THK SPEC IFIC TREATMENT PULMONARY' PHTHISIS. AND TUBEECULAE DISEASES. / • BY J. FRANCIS CHURCHILL, D.M.P. GRADUATE OK TTIE PARIS SCHOOL OF MEDICINE ; MEMBEB OP TOE IMPERIAL ACADEMIES OF MEDICINE AND SCIENCES. TRANSLATED FROM THE FRENCH BY A PHYSICIAN. SECOND EDITION, WITH APPENDIX. m? J. WINCHESTER, PUBLISHER, 43 JOnN STREET. 18G0. TREATISE Oil THK IMMEDIATE CAUSE, AND THE SPECIFIC TREATMENT or PULMONARY PHTHISIS, AND TUBEECULAE DISEASES. / BY J. FRANCIS CHURCHILL, D.M.P. chadcatji c3f th3 rasis school^ cf medicine ; membfb of teb imperial acade3he3 cf .:'-xiedicimk aot sctevces. TRANSLATED FRO&i! THE FRENCH BY A PHYSICIAN. SECOND EDITION, WITH APPENDIX. J. WINCHESTER, PUBLISHER, 43 JOHN STREET. 1860. C.513d. CONTENTS OF THE TREATISE. —----++-*-------- _ Tags. Author's Preface................................................................. 5 Report to Academy of Medicine. Juiy 21, 18577..... 7 .. 7.. 7 .7................... H Notes of Cases—Which resulted favorably.—(First Series).......................... 23 Notes of Cases—Without decided result.... —(Second Series)....................... 42 Notes of Cases—Which resulted fatally.—(Third Series)........................... 56 Remarks on Cases of 3.1 Series..................................................... 73 Additions to the Report................................"...."!!___'................. 74 History—showing prior experiments...............'___..... .".................. 82 Deductions—Physiological, pathological, kc.............t........'................... -1 ...----- APPENDIX TO THE FIRST EDITION. Memorial to Academy of Sciences, May, 1S58................................... P5 letters from Dr. Churchill.................................................... 97, 99,104 Phosphates and Hypophosphites—their chemical diu7renc'e.......................... 105 Bronchitis—Symptoms and Treatment............................................. 106 Asthma—Symptoms and Treatment___".."'.'"' '.'........................... 117 Chemical Pathology of the Brain..... ' ..................... 10$ • »• APPENDIX TO THE SECOND EDITION. Brompton Hospital Experiments—Dr. Quain's Report................................ Ill Brompton Hospital Experiments—Analysis of....................................... 115 Brompton Hospital Experiments—Dr. Cotton's Report.............................7 v.3 Hypophosphites in some diseases of young children—By Dr. Gibbs.............. l"5 Statistics, &c, of Consumption—By Dr. Millard.............................. I?; Notes of Cases—Reports by W. W. Townsend, M. D.....................*..........'..'." 131 Notes of Cases—Reports from New England Physicians.............................. 133 Hypophosphites in Consumption and Cerebral Disorders—By B. Walton, M. D___ 136 Further Report by Dr. Walton..................................................... 138 Alcoholic Treatment—Its effect in Consumption, and Relation to Disease........7'.' 140, 141 Report from English Physicians—Ismdon Medical Circular.............. 142 Dr. Dickson's Report—Visit to Dr. Churchill.................................. 7"' 143 Extracts from Medical Journals..........................'.. 7 7....... 7.7. .77771 144 --------►♦-.-------- GENEPiAL CONTENTS. Hypophosphites : Their Chemical Constitution............................ HO Their fi st Medical use, March 13,1855..................................... 15 Their Physiological and Therapeutical effects........................ 18, 20 Their immediate action on the Tubercular Diathesis.........'...'.".7.7 7 ' £1 Their action as Prophylactics.............................. 7 7l 76 95 * 93" 93 102 Their efficacy as blood-generating agents...............7.77 .7.....' .' 19 •/•> 75 Their power to increase nervous force...................7.7.77...... ' "»' 75 Their use ii Nervous Diseases and Paralysis........7.7. .7.77.77.7. .7....... "'21 Their use ia arresting hemorrhage.................'..7.7.7.77 37 Their influence in restoring the Catamenia.............7.7..... 20 '6 33' 36 "*» Their influence in checking Night-sweats............'.'.'.'.'.".'.'."' '' '" i.9 143 Their influence in checking Expectoration............................79 l4->' 143 Their influence ia Defective Innervation, or Nutrition ...7. "7......... ' "' 96 Their use indicated i:i Chronic Bronchitis and Asthma. ..7.7777.7............19 96 Their use indicated in Marasmus, Rickets, Anemia......777.........96 135 136 Their use in protracted Convalescence, Dobiity of Pregnancy...... ' 2'' 96 Their use in Spermatorrhoea, and ether morbid conditions___ 22' 95 Their premature suspension.............................. ............. ' 8, Their action as combustible substances.........7717777...........i3 91 14-> Their power to increase tho appetite..........7.7.77.77.7.............19 14;' 143 Their purity indispensable to success.........1 .. .7.7................. ' 80' 104 Lime and Sola, only, recommended for popular use............... 79'103 Hypophosphite of Potassa—Indicated in old inflammations ' ' 7a Hypophosphito of Potassa—In Bronchitis and Asthma . ....................19 44 78 Hypophosphite of Potassa—Augments expectoration, and hastens so'ftcniug....... ' 44' »« Hypophosphite of Iron—Induces congestion............... ........... ft Hypophosphito of Iron—Induces inflammation and hemorrhage 70 Hypophasphito of Iron—Its use dangerous........ ..................79 1 it Hypophosphite or Quinia—Tonic properties of;......77. .77........................ 1*9 Hypophosphite of Quinia—In Yellow Fever and Cholera..... ........ »« Cod-Liver Oil—What is its Value ?........... .............''q'kn"ii'*»"** ina Relation of Climate and Seasons to Treatment.....77. .'.7.7.7.7.7.7.7. 77. . .7. .'.75 94 Entered according to act of Congross, in the year 1859, by J. V?Mesik, in tho District Court of the United States for the Southern District of New York. PUBLISHER'S PREFACE TO THE SECOND EDITION. We Are not sufficiently impressed with the importance of the CONSTITUTION OF THE BLOOD IX THIS DISEASE. We are too much wedded to the old Idea ef treating the i/mritomt of consumption, and its (amplication)— havo too little faith in tho grand fact that It t« hy a better nutrition and a richer blood, and by this alone, that it is to be tared. It Is n grand idea that the patluitogieal ehemiilry of the blood Is to be carefully studied, with the view to RE- DUCE what is in EXCESS, or to SUPPLY what is LACKING, as we do through the soil to the sap—tie blood of tho plant.—[Child; On Rational Medicine. Since the publication of the First Edition of Dr. Churchill's Treatise in this country, tho atten- tion of tho Medical World has been largely directed to an investigation of the therapeutical action of the Hypophosphites ; but the philosophical scope of the Theory, out of which the use of the Hypophosphites sprung, has never been clearly recognized until within a very recent period. It is not alone in tho field of Therapeutics that the Author has gathered the immortal laurel, but the paths of Physiology and Tathology have yielded him a like harvest. The first to pro- mulgate the distinctive doctrine, that the inorganic constituents of the fluids of the economy are those essential parts of them which modify the functions and the constitution of all organic mat- ter, he was likewise the first to apply tho doctrine to the treatment of disease. And he begun with the most formidable. He engaged with the subtle adversary that slays one-sixth of tho civilized world ; and it is now attested by many voices, to which the world Will- ingly listens, that with him remains the victory. So. instead of blinking such contradictions of his theory, and denials of his conclusions, afl havo occasionally appeared, tho publisher has embraced in the new Appendix the most elaborate and able of these—exhuming it from the obscure crypt in which it lay buried, and making it the " subject " of an instructive past morion. Tho same Appendix contains a brief chapter " On the Chemistry of the Hypophosphites,1' which, being written in popular language, is particularly commended to the attention of the general reader To the physician, a clear apprehension of tho Chemistry of the Hypophosphites, and a distinct recognition of the extent and nature of their difference from other preparations of phosphorus, are necessary tc their intelligent exhibition. The one essential indication in Pulmonary Phthisis, according to Churchill, is exydizall: phos- X'Korui Those practitioners, therefore, who exhibit the TnospnATES, cither do not understand the indications or they are not familiar with the Fpecific chemical constitution of these salts. Many humiliating mistakes will bo avoided by bestowing a little attention upon thissubject. The Pub'.isher commends the remarks of Dr. Churchill, and especially those of M. Trousseau, or tht ust of iron, to the gravest consideration ; and it should not escape the attention, cither or the invalid or the physician, that the most active treatment of phthisis, with the Hypophos- phites. should be employed during the summer months, at the very period when treatment of every kind is commonly suspended. 43 John Street, New Yons, July, 1C60. PUBLISHER'S PREFACE TO THE FIRST EDITION. " Not only is chemical science capable of pointing out tho eiact chemical constitution of the body, and the change* and transformations which aro constantly occurring, but it has proved competent to direct us respecting the proper methods *y which certain elements, or agents, may ba furnished when pathological symptoms indicate an INSUFFI- CIENT SUPPLY."—Bolton Medical and Surgical Journal. The Treatisa of Dr. John Francis Churchill, announcing to the world the mest brilliant dis- covery of medical science during the past century—that of the therapeutical action of the Hypo- phosphites in Phthisis Pulmonalis—needs no commendation to insure for it a careful perusal and tho earnest consideration of both tho professional and non-professional public. ThaUthe translation will be found to contain errors, is probable. These, however, the gcod sense of the reader will correct. In the " Notes of Cases," we havo used condensation and abbre- viation, where tho details were merely the daily repetition of treatment without particular chango ia the symptoms. In every case, tho translator has faithfully preserved the material facts con- nected with the specific treatment,.so as to present a full view of the changes ia tho symptoms pro- duced by the remedy. As the translator of tho work is himself a physician, we be'.ieve tho abridgments made by him in no respect impair tho value of the record of tho cases. The importance to the world of a discovery which promises to render Consumption amenable to medical science, so that. " instead of occupying the first place in the causes cf mortality, it will dwindle down to a comparatively insignificant item," must be manifest to all. Tho results already obtained by the use of the Hypophosphites in Tuberculosis, fully confirm the claim, that it is the specific remedy against toe diattiesis. Though, on the first announcement of the discovery, it was received with disfavor by many eminent members cf the medical pro- fession, opposition to the treatment is rapidly disappearing under tho accumulating evidences of the efficacy of the remedy in every case in which it has been intelligently exhibited. I'p to the period of Dr. Churchill's discovery, the Hypophosphites were possessed of no commercial value, being known only as beautiful specimens in the laboratory of tho chemist. "It is not very astonishing," says Dr. Churchill, "that tho Hypophosphites which are new ordinarily sold, and which have beon prepared in consequence of the great demand created since my report, should not always present that purity indispensable to success in tiis treat- ment. In five cases out of six they are totally unfit for medical use." It is to this impurity, as well as to many " crude formula?" that havo been imagined by uninformed practitioners, that wo must attribute any ill-success that may have followed the use of tho remedy ; and it is against these impure preparations and "crude formula," that the profession and tho ublic need to be protected, and tho benefits of tho discovery thereby secured to the sick. It was, therefore,an important consideration, in undertaking tho introduction of Dr. Church- ill's treatment in tho United States, to guard tho patient from the dangers that threatened him from the ignoranco or tho charlatanry which never fails to seize upon and desecrato whatever is valuable. Preparations of tho most absurd and deleterious character have been palmed off even upon tho medical profession, under tho name of Hypophosphites ; and others, containing inert, or injurious elements, invented to satisfy tho greed of some mercenary trifler with tho lives of sufferers, have been successfully advertised and sold, thus retarding the realization of tho inestimablo benefits which must result from the speedy adoption of tho authentic treat- ment. 43 Jons Street. New York, June 1859, PREFACE OF THE AUTHOR. "We are going to consider the most cruel enemy of the human race, and to consider the means of contending against it with success."—Louis on Phthisis. "Taking as a basis the sum generally considered as that of the population of the globe, it is fair to estimate that from eighty to one hundred millions of its inhabitants succumb, by a pre- mature death, to some form of this disease. It destroys nearly a sixth of the population of England."'—Ancell on Tuberculosis. " England pays an annual tribute of nearly sixty thousand deaths from pulmonary phthisis. " Figures extracted from the bills of mortality of London, show that eighteen deaths (more than one-sixth,) out of every hundred, depending on no matter what causes, arise from those tuber- culous diseases." " The ratio of mortality from phthisis, is very nearly the same in Taris as in London."—Bou- din, Medical Geography. The circumstances which induce me to lay this book before the pub- lic, demand, in my opinion, some explanation. The Academy having referred my Report to a " Section," it would have been equally in harmony with my interest and my wishes to have waited, according to the usual custom, the result of its deliberations. Both science and humanity had every thing to gain by having my pretensions, at as early a period as possible, either coincided in or con- demned by such a recognized authority. Unfortunately, the present condition of science, or rather, I should say, of medical opinions; the singular prejudices which exist as regards questions of therapeutics— the very object of my book—and perhaps the means adopted in order to solve the problem which I had undertaken :—all these causes con- spired to convince me that it would be in vain, to wait for the official judgment of the Academy. Assured of this fact by reliable informa- tion, I decided to publish my Report, in order that each persou might have an opportunity to judge of and employ my method of treatment under the conditions indispensably necessary for its success. A number of practitioners, both in France and England, have already commenced to experiment, and many have written to me for informa- tion upon the subject. The nature of the information sought for has convinced me that it was my duty to explain my plan of treatment in all its details. When the results of these experiments shall become known, I think that the Academy, itself, will not longer delay an exam- ination of the facts established by a large number of observers. With 6 PREFACE OP THE AUTHOR. the exception of some few typographical corrections, I have reproduced my Report precisely as it was presented to the Academy. I have also appended to it the notes of the cases upon which it is based, compris- ing all the cases which have been submitted to my treatment, no matter what was the result; for it is in this way only that the value of a rem- edy can be estimated. A single case has been kept back, it being still under treatment. Under the chapter entitled " Additions to the preceding Report" I have replied to the objections already made, and laid particular stress on certain points which I had only referred to in my Report. In the his- torical sketch, I have pointed out the progressive steps in the investiga- tion of this subject, made by different experimenters, some of them long anterior to me, others very nearly contemporary. In this I have endeavored, as far as is ever permitted to human weakness, to judge the merit of each one fairly. Finally, under the head of " Deductions," I have indicated certain consequences of my theory in regard to tuberculosis, of which I have not yet established the exact data; but which I hope hereafter to be able to examine and determine more fully, especially in their chemical relations. This book is, in truth, but a sketch of the work which I had projected; but the state of my health, and above all the circumstances attending its production, have prevented me from extending it to a greater length. The causes which have hitherto frustrated my efforts are, I think, of sufficient general interest to make it proper to detail them here. Hav- ing obtained, at Havana, the notes of the results of those cases which comprise the first in each of the series to be hereafter given, I deter- mined upon returning to Europe in order to pursue my researches and establish my discovery by incontestable facts, outside of the special in- fluences of climate, etc. On my arrival, in May, 1856, I deposited with the Academy, on the 3rd,of June, a sealed packet containing full details of my method of treatment, and of the reasons which had induced me to experiment with it. This constitutes very nearly the first ten pages of the following Report. The reason for not at once publishing this note was, that on such a subject, and after the numerous failures experienced by other observers, it was certainly allowable, even if it was not my duty, to dis- trust myself, Notwithstanding my own conviction that my theory was correct, I bad not yet made it a scientific certainty. Seeking, therefore, to estimate the results which I had already ob- PREFACE OF THE AUTHOR. 7 tained from the point of view of an indifferent observer, I could not conceal from myself their insufficiency, particularly when I remembered that the subject to which I wished to call the attention of practitioners and obtain their concurrence, was Consumption : and at a period, too, when skepticism in therapeutics is notoriously the predominant senti- ment of the professional world. On the other hand, I confess that I was ambitious, as was both natural and right, to finish what I had myself commenced. The duty of every physician, as soon as he has arrived at a certain practical conclusion, is to publish it, because it interests both the health and life of mankind. For the reason, also, that the existence of his fellow-beings depends upon it, he should advance nothing without due consideration. It is only when the truth of any new hypothesis is firmly established in his own mind, that he should endeavor to influence its adoption by others. A different course results only in discredit. and reacts injuriously upon the cause of science. This being my opinion, I addressed myself to several members of the faculty of the college, as also to the physicians of the hospitals, ask- ing permission to attend some of their patients, and engaging to observe the following conditions : Firstly—That I would establish to their satisfaction the safety of my treatment. Secondly—That I would demand the opening of the note, deposited with the Academy, as soon as the chief of the medical staff thought the results obtained were sufficient to inspire confidence in the real value of my plan of treatment. Thirdly—That I would abstain, during the period occupied in these trials, from any, except a gratuitous, exercise of my profession. I proposed this last condition myself, and I have never deviated from it from the day when I commenced my experiments in the hospitals, up to the time when I made known the curative means which I employ. My remedies also have always been furnished without remuneration from any one. This fact constitutes a sufficient reply to the insinuations of certain English journals. After I had applied in vain to several of my fellow-practitioners, as well as to my former teachers, M. Charles Bernard, with a degree of moral courage which does him honor, consented to entrust to me some few of his patients in the wards of the hospital La Charite. These cases will be spoken of hereafter. Although the results, in consequence of the advanced stages of the disease, were far from being as favorable as I 8 PREFACE OF THE AUTHOR. should have wished, they nevertheless appeared sufficiently remarkable to M. Bernard, to induce a continuance of the investigations. It was, therefore, agreed that I should choose, at the office of admit- tance {bureau central), a certain number of patients from those which seemed to me to present the most favorable chances for cures. This I at once proceeded to do; but at that very moment an order from the administration was received which forbid M. Bernard to continue longer the trial of my treatment. M. le docteur Briquet, feeling confidence in me, proposed in his turn to entrust me with one of his patients. This is the case numbered as the twenty-eighth. The result of the treatment in this case was unfortunate, for the reasons which I have given in my notes. In this manner six months passed, and yet the number of cases which I had been enabled to treat in the hospitals, during the whole of this time, amounted to only nine, of which five were in such a desperate condition that it was the height of rashness on my part to undertake them at all. Professor Bouillaud had also the kindness to entertain my proposal, but a circumstance, unconnected with the subject, prevented me from profiting by the courtesy which he extended to me. This prolonged trial had, however, shown me one fact: that the hos- pitals of Paris were, for the most part, designed for the treatment of acute diseases, and that persons suffering from affections of the lungs were seldom admitted, except at a very advanced stage of their disease. It would, therefore, have been difficult, if not impossible, for me to ob' tain more than one or two curable patients from the list under the charge of any one physician; at the same time this would have almost indefinitely prolonged the time for my investigations. I determined, in consequence, to go to London, in the hope of obtaining in the hospitals especially designed for the treatment of consumption, a sufficient nunJ- ber of cases, especially of those in the earlier stages of the disease, to enable me to arrive at some solution of my hypothesis. I took my departure for London: but a long sickness, consequent on change of climate, and important domestic matters, prevented me from pursuing my plan until the month of May. At that time I forwarded my request to the board of direction of the Consumption Hospital at Bromp- ton ; it was rejected. Some communications, which I addressed to one or two of the medical journals of London, for the purpose of explaining the objects of my proposal and the reasons which- influenced my course, served only to draw upon me attacks as unjust as they were illiberal. PREFACE OF THE AUTHOR. 9 In a personal interview with one editor—having for its object certain verbal explanations—I was received in so singular a manner that, taken in connection with other circumstances which happened in my inter- course with some of my fellows, I felt so little encouraged that I deter- mined to leave the country. The treatment I experienced appeared to me all the more unmerited, because, during the time of my stay in Lon- don, I neither saw nor attempted to see a single patient. The only thing which, can explain this conduct of the English medical press toward me, is my having said to two or three professional gentlemen that I hoped to establish, at my private expense, a dispensary for the gratuitous treatment of consumption. I imagine that, to certain persons, this project appeared incredible ; or that, supposing it to have been really intended, they saw in it a pernicious example. Convinced, moreover, by a careful examination of my collection of facts, and the general aspect of the whole question, that the theory which this work details, was correct, and believing that I had done all it was in my power to accomplish—since I had recoiled before no sacri- fice or personal inconvenience to bring to a satisfactory conclusion that which I had commenced—I determined to offer my work for discussion, even in its present imperfect condition. For this purpose, in July, I re- turned to Paris, and immediately presented to the Academy the Report which I now give to the public. If any should ask why I did not wait for the collection of a greater number of facts, before declaring, as boldly as I have done, the truth of what I advance, I reply : that it is'not the number of favorable cases, but their relative agreement, which gives weight. I will recall to their minds that Jenner proclaimed his discovery of vaccination when it was based upon twenty-three cases only. Finally, I wish also to re- mind them that every new idea in medicine is not wholly acquiesced in until the foundation upon which it rests has been established by the ob- servations of several independent experimenters ;—the discoverer himself having no other claim in the matter than that of being the first to indi- cate the facts from which he formed his conclusion, and of fixing the conditions under which each individual should test it, in order to be able to verify for himself the truth of the doctrine propounded. It is true that I should have preferred not to have presented myself to the public, except well fortified with corroborative proofs, in order at once to command that degree of interest which the subject deserves. I have already given the reasons which prevented me from doing this. If, therefore, there shall be some delay in diffusing the truth, some injury 10 PREFACE OF THE AUTHOR. done to the reputation of our profession, some prolongation to the suf- ferings of many of our fellow-men, let the fault rest with those who occasioned it. I have already felt, to its fullest extent, the responsibility of my position. If some of those with whom I have had intercourse had experienced this feeling in the same degree, this question would have been decided long ago. In addition, the cases which I have examined up to this time, subse- quent to the presentation of my report, (of which there are now twenty under treatment either in my own practice, or in that of some friend,) all offer such uniform results, and are so much in accordance with my theory, that I have no longer any hesitation in proclaiming, as an estab- lished truth, that a specific remedy against the tubercular dia- thesis is found. In conclusion, I desire to state that all my relations with my French professional brethren have been characterized by generous cordiality on their part, I have often encountered, at the preliminary slatement of my theory, a skepticism which was natural, and up to a Certain point proper; but from most of them I have received the warmest expres- sions of sympathy, and on every hand that true courtesy which ca-i come only from those who themselves command respect. The French medical journals have, all of them, published the conclusions at which I have arrived; and several have particularly called the attention of their readers to the subject. I regret that I can not say that a similar courtesy has been exhibited toward me in England ;—for such has not been the case. Time, the beneficent antidote for all injuries done us, will show how much science has suffered by such a course towards me. I wait, confidently, antici- pating the period when justice will be rendered where it is due. I have indulged in these personal details only because they appear in connection with an important question, involving in the highest deo-ree the future position of the healing art; viz., whether we should not allow each conscientious inquirer an opportunity to investigate whatever the- ories may be proposed in therapeutics, precisely as it is permitted in every other branch of human labor, with such restrictions only as are demanded by a proper regard for humanity, and due care in experiment ? The search for the truth in medicine, is of itself so difficult that we should endeavor to avoid, as much as possible, impeding it by obstacles that do not depend upon the investigation of the subject itself. PAEia, September, 1857. ON THE IMMEDIATE CAUSE AND ON A SPECIFIC TREATMENT or TUBERCULOSIS. A REPORT PRESENTED TO THE IMPERIAL ACADEMY OP MEDICINE, PARIS, JULY 21st, 1857. Gentlemen, Members of the Imperial Academy of Medicine : I have the honor of submitting for the consideration of the Academy, the results at which I have arrived with regard to the Imme- diate Cause of, and a Specific Treatment for, the Tubercular Diathesis. In the month of June, of last year, the Academy received from me a sealed package, containing an exposition of my views upon this subject. I wished at that time to collect a greater number of facts in support of my discovery, in order to advance nothing which might seem trivial upon so important a matter. Unfortunately, the state of my health compelled an interruption of my labors; the proofs, therefore, which I herewith present, are far from being as numerous as I could have wished. I nevertheless hope that, meagre as they are, they will not appear un- worthy of your attention. The first idea which I had upon this subject—that which induced me to investigate it—and which, I conceive, furnishes a clue to that myste- riously morbid condition, entitled Tuberculosis, dates from the month of February, 1855, while I was engaged in the practice of my profession at Havana. Occupied as I have been, since the commencement of my medical career, in researches upon the treatment of phthisis, my investigations led me to believe that the tubercular diathesis depended wholly upon some disturbance of the primordial functions of life; that, considering the in- timate union which exists between all parts of the body, this disturbance must have, as a proximate cause, some important modification in the 12 REPORT TO THE ACADEMY. process of sanguification. The works of various pathologists, especially those of MM. Andral and Gavarret, the correctness of which has since been confirmed by others, indicated that the variations in the composi- tion of the blood, in pulmonary phthisis, had no peculiar and important relation, as far as its organic elements were concerned. I was, conse- quently, induced to believe that it was among the inorganic elements of this fluid that we should look for the special cause of this diathesis. On this point the works of chemists were either incomplete or contra- dictory. I therefore decided that therapeutical experimentation alone could furnish a solution, and accordingly determined in that way to dis- cover, if possible, the influence upon the progress of consumption occa- sioned by changes in the inorganic elements of the blood. As the phenomena of this disease, approximating to those of many other morbid states of the body, and especially to chlorosis, appeared to me to be attributable to the loss, or diminution, rather than to the aug- mentation of some essential constituent, I decided to commence my experiments by increasing, if possible, the quantity of this element; consequently, all that was left for me was to determine what substance I should choose for experimentation. Medical science furnished a numerous collection of data going to show the influence upon the economy of the greater portion of these chemical elements: as, for instance, iron, sulphur, (whether in the state of a sul- phuret, or as a sulphate), and the chlorides. The use of alkaline reme- dies was an every-day occurrence—all, or nearly all, had been tried in the treatment of tuberculosis; and although each one of them, in its turn, had been extolled, neither of these agents had presented sufficiently well-marked, or uniform effects, to establish its claim as possessing a real curative influence over the disease. I therefore deducted these substances from those with which I designed to experiment, intending subsequently to take them up, should I find it necessary. I decided to commence my investigations by the use of phosphorus. We know, gentlemen, that this element is one of those most con- stantly present iii the human body, but that is the extent of our knowl- edge : chemistry not having yet been able to determine the state in which it exists in the blood. Does it enter into its composition in the form of phosphoric acid, or does it exist simply as phosphorus, mixed in an uncombined state with the organic elements ? At that time I had never seen the experiments of Dr. Rees, published in the Philosophical Magazine for 1848, and the position which he has there assigned this element in the functions of the blood globules; but in addition to this REPORT TO THE ACADEMY. 13 work, which was then entirely unknown to me, I found the whole sub- ject examined and illustrated very clearly, up to a certain point, by the labors of others who had engaged in therapeutical inquiries. The phosphates, especially the phosphate of lime, had already been employed in the treatment of rachitis. I knew also that Dr. Benekc had proposed, in 1849, in Germany, the use of it as a specific remedy against the tubercular diathesis, and that other investigators, among whom was Dr. Piorry, had also employed it. On an examination, how- ever, of all the facts conuected with its use, I became satisfied that this remedy had not exhibited that immediate and decided action upon the disease which I judged the element to which it was analogous, viz., phosphorus, really possessed. Is it in its original state, then, that phosphorus has its remedial ac- tion ? Looking over the physiological effects which this substance is known to produce, as detailed in the Bibliotheque de Tlierapeutique of Bayle, I was impressed with the idea that the remarkable phenomena of stimulation which he describes, as well as its known action in various morbid conditions of the body, would render it useful as a remedy in consumption. On the other hand, MM. Barthez and Rilliet, in their work on the diseases of children, after citing two cases of tubercular meningitis cured by Coiudet, in the year 1802, by means of phosphorus, assure us that their trials with it have given " no favorable result, not even of momentary duration." Again I was arrested in my inquiries by nega- tive or contradictory reports. On reflection, however, it seemed to me that these apparently opposite results were capable of being reconciled with each other. In fact, after admitting that the phosphorized element of the blood, or of organic matter, exists in the body in some other form thau that of phosphoric acid, it was evident to me that it performed the double part of an eminently combustible substance, and at the same time entered into molecular combination with the other elements of the body, in such a way as to become an integral portion of it. But neither phosphoric acid nor phosphorus can fulfill this double indication. The former is already at its maximum of oxydation : the latter, placed in contact either with the liquids in the stomach, or with any of the tissues of the body, must necessarily, before being absorbed or fitted for assimilation, become transformed into phosphoric acid, or the phosphorous or hypophospho- rous acids : compounds next lower in the degree of oxydation. In the first case, the same results would be obtained as from the em- 14 REPORT TO THE ACADEMY. ployment of simple phosphoric acid, with the addition of the serious inconveniences resulting from the local action of the phosphorus : in the second case, even allowing that the phosphorus, before being absorbed, should be transformed into hypophosphorous acid, this should at once, on being brought into contact with the alkaline principles of the blood, transform itself into two equivalents of phosphoric acid and one of phosphorous acid (Ph3 01S=2 Ph 05 + Ph O3). This last would fulfill the two conditions which I have stated above, but with the disadvantage of presenting, under the most favorable conditions, only a portion of the phosphorus taken into the stomach; while the remainder, by its transformation into phosphoric acid, loses its special power of action. In this view of the case, as the action of this preparation of phosphorus upon the human organism would depend on the quantity of the element capable of oxydation at the moment of absorption, or assimilation, the efficiency and certainty of the remedy would be subject to conditions over which we could have no control : for instance, upon the liquid in which the remedy might be dissolved, the age of that particular prepa- ration, the nature of the substances it might encounter in the economy, the activity of its absorption, &c. These reasons explain, to my mind, the causes why the preparations of phosphorus have proved so untrustworthy ; and why, on the one hand, Coindet was enabled to obtain certain satisfactory results upon employ- ing it in large doses, while MM. Barthez and Rilliet, with much less doses, obtained only unfavorable or negative ones. Being satisfied that I have discovered the reason for these apparent contradictions, I believe I can logically establish the following double hypothesis : " The tubercular diathesis depends upon a diminution in the system of the phosphorized element, and which, having to act the part of a combustible body, should be found at a lower degree of oxy- dation than that of phosphoric acid." After I had formed this mental induction, nothing remained for me but to verify it by facts, and to choose which, among the various com- binations of phosphorus with oxygen, viz., the oxide of phosphorus, the hypophosphorous, or the phosphorous acid, I should use. My de- cision was based upon the following considerations: The red oxide of phosphorus is insoluble and very inflammable ; the yellow variety, although soluble, forms combinations with bases which are very slightly so, and are, by no means, permanent. In addition to this, there was an objection in the difficulty of its preparation under the circumstances in which I was then placed. REPORT TO THE ACADEMY. 15 I judged that phosphorous acid would have an action much less en- ergetic than hypophosphorous acid, it being less combustible, since it contains three equivalents of oxygen, while the latter is combined with one equivalent only. The salts formed from the former, which are soluble, are those of soda, potassa and ammonia, while all the hypo- phosphites are soluble in water. I therefore chose the hypophosphorous acid, and decided to use it combined with abase. The use of the acid itself, uncombined, seemed to me to offer no particular advantage, since at the moment it is absorbed it enters into chemical combination with the alkaline carbonates of the blood. There was also the additional objection that it was difficult to divide it. into doses; for if used, it would be necessary to determine, each time, the degree of concentration of the acid. From preference I chose to commence my experimenta- tion with the hypophosphite of lime, on account of the important part which this base is supposed to play in the system. But then I was wholly ignorant what were the effects of this salt when taken into the body. The only mention which I found in the works consulted, was, that according to toxicologists generally, (and I believe among them were included Orfila. and M. Devergie,) the poison- ous effect of phosphorus is to be attributed to its transformation into hypophosphorous and phosphorous acids. It was necessary that I should proceed in the use of this preparation with the greatest caution. I therefore determined to try its effects in the first instance upon my- self. For this purpose I commenced by taking half of a grain of hy- pophosphite of lime, which quantity I gradually increased to six grains at a single dose, without experiencing the slightest inconvenience from its effects. Convinced by this trial of the physiological safety of the agent, taken at that dose, I tried it for the first time, on the 13th of March, 1855, upon a young woman of nineteen years of age, affected with acute tuberculosis as a sequel to pregnancy. Both lungs were completely in- filtrated with tubercles at the commencement of the first stage of soft- ening. There was also enormous distension of the abdomen, with acute pain on pressure, a high degree of fever, extreme prostration—in fact, all the signs of peritonitis in full progress to a fatal termination. The first day the patient took one grain of hypophosphite of lime ; on the third day the dose was increased to six grains; on the fourth day, she could raise herself in bed, and asked for some nourishment. The change in her condition was so rapid, the amelioration of all her general symptoms, the night sweats, fever, prostration, &c, was so 16 REPORT TO THE ACADEMY. surprising; her appearance, above all, was so much altered for the better, that I was completely astounded. My patient continued steadily to improve every day until the eighth, when she suddenly sank, and died with the symptoms of a perforation of the intestines. The second case submitted to this treatment was a young lady six- teen years of age, also from Havana, whom I had treated the year pre- vious for the incipient signs of consumption, but which symptoms had yielded to a treatment of inhalations of atropine combined with a strengthening regimen, and residence in the country. In the month of February, 1855, the disease again made its appearance, and resisted all the means previously tried for its relief, as well as the cod liver oil and emetics now used. The unfavorable symptoms developed themselves rapidly, and at the commencement of the month of April she presented the following condition: fever and chills at night, great emaciation, complete loss of strength and appetite, profuse night sweats over the chest and about the neck, a constant cough which fatigued her very much, slightly mucous expectoration with small stria? of blood, and cat- am«nia much less abundant than natural. On percussion, I found a marked diminution of resonance in the upper portion of the right lung, especially noticeable in front; much moist crepitation over the same locality, heard quite distinctly during the cough ;—while over the other portions of that lung the respiration was decidedly increased. The left lung appeared healthy ; the voice presented nothing remarkable. The symptoms appeared to me sufficient to justify the diagnosis of tubercles approaching the period of acute softening, and I therefore commenced at once the treatment by ordering four grains each day of the hypophosphite of lime, which soon afterwards was increased to six. Under the influence of this treatment, all her symptoms were rapidly ameliorated. I continued this course with occasional intermis- sions, which I shall speak of further on, until the close of the month of May; and at the end of June I established, to my own satisfaction, the fact that no traces existed in my patient either of general constitu- tional disease, or of those physical signs which I had discovered at the commencement of the month of April. I will not, at this time, occupy the attention of the Academy, but will reserve for another occasion all the details of my other observa- tions, which I hold subject to its examination, and will only present the general result which I have arrived at from the aggregation of my cases. The whole number of cases treated by me amounts to thirty-five ; of REPORT TO THE ACADEMY. 17 this number, nine were completely cured; eleven experienced an essen- tial amelioration ; fourteen died, and one still remains under treatment. Of the nine cases in the first series, eight were in the second stage, that is, presented tubercles in process of softening; in the ninth, there was a large cavity situated in tho superior portion of the left lung. Three cases had acute symptoms ; one of these, that of a child of seven years of age, showed also well-marked symptoms of cephalic disease; one alone of these was perhaps doubtful, because the physical signs were confined to the base of the lung. All the symptoms in the cases in the second stage, both rational and physical, entirely disappeared, and the lungs, I am satisfied, were restored to their normal healthy condition. In the ninth case, that of the patient with the cavity, all the general symptoms disappeared, while the physical signs were also notably improved. There still remains, however, some cavernous respiration, but no rales or crepitation; the cough having also ceased, and the ex- pectoration being scarcely perceptible and perfectly transparent. A year after the discontinuance of treatment, he wrote to tell me that his health continued unchanged, and that he felt himself well enough to undertake the drudgery of a brisk business. I have also heard from two of my other patients, whose health remains perfectly established. From the others I have no information. Of the eleven cases which I have spoken of as simply relieved, fom were in the third stage, and presented large-sized cavities. In one of the patients these cavities occupied portions of both lungs. In view of the results obtained from these cases, and especially from the well- marked and prolonged amelioration which existed in two of them which had cavities, I have every reason to believe that unless some complica- tion had intervened, both would have recovered under a continuance of the treatment. The seven other cases presented a well-marked alle- viation of symptoms, which was maintained without interruption during the course of treatment. One case alone, in which there Avere some abdomiuaF complications, presents an exception. In one case, where there was a cavity occupying a large portion of one lung, the diarrhoea which existed disappeared, and did not again make its appearance as long as the treatment was continued. I wish now to speak of the fourteen cases which resulted fatally Before commencing the treatment, I looked upon them as nearly hope- less. In six, there were cavities either of immense size or several in number ; in three of them, in both lungs at the same time. One other was, in addition, attacked with peritonitis. Eight were affected with 2 18 REPORT TO THE ACADEMY. diarrhoea, and most probably with ulceration of the intestines ; in two, the tubercular mass occupied more than a half of each lung; in three, it extended through the whole of one lung; in one, the upper lobes of both lungs were affected; and finally, in one, the tubercles were con- fined to the apex of one lung, but there existed, in addition, a severe Iaryngial affection. Seven of these patients were in such a condition that they died in one month after the commencement of treatment, four others within two months and a half, while three only lived over three months. This simple statement is sufficient to show that nearly all these pa- tients were in such a condition, when treated by me, that they could do no less than bring discredit upon my theory, and upon myself, as its originator: notwithstanding which, I deemed it my duty, under the circumstances, to lay aside all personal feeling, as I was anxious to in- vestigate the difference, if any existed, between the results obtained under the climate of Europe, and those which I had noted under the tropics,—where, I am satisfied, several of these cases would have experi enced a more decided, as well as persistent, amelioration. I will now pass to a consideration of the proper doses to be given, and the physiological and therapeutical effects of this new remedy. I have employed the hypophosphites of lime, of soda, of potassa, and of ammonia. The last two were tried but a few times only, for their action seemed different from that of either lime or soda. The first two seemed to be of very nearly equal efficacy. I have used them either alternately, in the same case, or one wholly, to the exclusion of the other, without discovering any perceptible difference in the result. One of the cases of acute phthisis, which recovered, was treated entirely by the hypo- phosphite of soda. The most effectual dose I have found to be twenty grains, taken at a time, once each day. Generally, I commence with ten grains, and gradually increase from day to day by from two to four grains. In some few cases, I have given as much as a scruple and a half, repeated twice each day. Every ten or fifteen days, I suspend the treat- ment for a day or two, and then again recommence. In the cases of two children, both under seven years of age, I employed the salts at a dose of from one to two grains each day. The physiological effects, proved both by trial on my own person and on my patients, are of two classes : There is a well-marked increase of nervous force, often manifesting itself from the first day, accompanied with a most remarkable sensation of strength and health. At the same time the nervous troubles, if there REPORT TO THE ACADEMY. 19 are any, disappear, as well as all functional disturbances, such as oppres- sion of the stomach. The appetite increases often at the most extraor- dinary rate. The evacuations from the bowels become regular and more abundant. The night sweats, if there are any, cease; and the sleep becomes calm and profound. The effect produced upon the nutritive functions, are equally decided: the features will change completely, often in the space of a few days; acquiring both fullness and color. Sometimes the teeth and hair show this nutritive stimulation. In one patient whom I treated at La Charite, a boy seventeen years of age, of a feeble, lymphatic constitution, who was cured of a tuberculous infiltra- tion of the whole of the right lung—in the first stage, but in process of softening at the apex—the beard commenced growing rapidly two months after placing him under the treatment. A young girl placed under my charge by Dr. Lemaire, in a fearful state of marasmus, with cavities occupying more than a half of one lung, experienced not only decided amelioration of all the symptoms, but during the treatment her four wisdom-teeth made their appearance. A treatment of six weeks by the hypophosphite of potassa, completely dissipated all the symptoms in an old man sixty-five years of age, for two years a sufferer from the most violent attacks of asthma, depending upon a chronic bronchitis. He was so reduced that he could scarcely visit me even in a carriage, but rapidly acquired the strength and ap- pearance of a man of fifty. About fifteen days after the cessation of treatment, he was attacked with a carbuncle on the neck, for which he was treated by Dr. Michon. His recovery was long and difficult, and yet he was finally fully restored to health. I think that this was more than a simple coincidence. All these peculiar symptoms seem to depend on, or at least correspond with, a decided stimulation in the powers of sanguification. The quantity and color of the blood increase so rapidly that I do not hesi- tate to say that the preparations of hypophosphorous acid are the most valuable blood-creating agents known. Every case has shown, within a very brief time after the commencement of treatment, well-characterized symptoms of plethora; and I have every reason to believe that, in some cases of advanced disease, this state would stimulate the development of that pulmonary inflammation, unhappily so frequent and fatal among consumptives. Hemorrhoids will bleed under its influence, for the first time, or re- commence if once the hemorrhage has been stopped. In one case I made them bleed at pleasure, for the experiment was tried at three dif- 20 REPORT TO THE ACADEMY. ferent times. One patient was troubled by marked symptoms of cerebral congestion. Four had an abundant epistaxis. In one alone was there hemoptysis, and this but of one day's duration, which stopped immedi- ately on the cessation of treatment. Finally, in all females in whom the disease was not too far advanced, the catamenia became more abundant and highly colored. I have not noticed that this remedy possesses any effect over the functions of gene- ration other than that which might be attributed to its general stimula- tion of the system; but this is a point which I have not yet examined. The following are the principal therapeutical phenomena which.I have noticed in the patients who have submitted to this treatment. When the remedy is given in the proper doses, the patient feels on the second or third, and sometimes from the first day, a decided increase of strength and appetite. I am satisfied, by repeated and careful trials upon myself, that these phenomena are by no means chimerical. The pains over the chest, which many patients feel so acutely, either cease, or very considerably diminish within a few days. The night sweats, however copious they may have been, almost always disappear at the end of seven or eight days. When, however, the intestinal canal is affected, and there is persistent diarrhoea, this is not always the case; the sweating then remains obstinate, particularly toward the close of the disease. At the same time the strength and appetite return, the patient gains flesh; the features, especially after the first fortnight or three weeks, presenting a striking improvement. The influence of this treatment upon the cough and expectoration, has been equally rapid, and has often caused their disappearance or alleviation within a very short space of time, frequently in even two or three days. In this respect there is, however, in the various cases, a very decided difference, which has appeared to me to have an intimate relation to the extent and gravity of the lesions as shown by auscultation and percussion. There is one fact which I wish especially to be noticed ; for I think it is universally true, that all else being equal, the local lesions are relieved by this treatment with much greater rapidity when the disease is of more recent date. For instance, in many patients of the first series, physical signs more marked and covering a greater space, have disappeared, while they have obstinately remained, or were much more slowly alleviated, in others of the second series, although at the commencement they were much less formidable. In all cases this dif- ference coincided with the difference in the time the disease had existed, and it seems to me can be explained in no other way. REPORT TO THE ACADEMY. 21 The intestinal troubles have proved generally rebellious to treatment when they possess a certain degree of severity, and a persistent diar- rhoea has always brought a fatal termination. The fever has given a more various result, according as it seemed to depend upon the general diathesis, or the pulmonary lesions themselves. From what I have now stated, I think I am justified in drawing the fol- lowing conclusions, upon which the Academy is requested to pass its judgment: The immediate cause, or at least one essential condition ov the tubercular diathesis, is the diminution in the system of phosphorus which is found in it in a form capable of oxydation. The specific remedy for this disease consists of a prepara- tion of phosphorus which presents the double characteristic of being immediately absorbed or assimilated, and which at the same time is at the lowest possible degree of oxydation. The hypophosphites of soda and lime, up to this time, seem to me the most completely to unite these requisites. This treatment has an immediate effect upon the tubercular diathesis, so called, and causes the disappearance, with a really marvellous rapid- ity, of all those symptoms which generally typify its existence. When- ever the morbid deposit which is at the same time the special result and the pathological evidence of this diathesis, is of recent date; when- ever the softening has only just commenced, and proceeds slowly, the tubercles are absorbed and disappear, leaving no trace. When the deposit is of an older date, or when the softening has reached a more advanced degree, it will sometimes remain in spite of the treatment; in which case the result of the disease will depend upon the anatomical characteristics of the lesion, and above all upon its extent, and the presence or absence of complications. Numerous trials made by me to remedy the local condition, by a direct medication by means of the inhalation of various substances, have, up to this time, produced no satisfactory result which could not be attributed to the improvement consequent upon the specific treat- ment. Nevertheless, if we can now arrest the progress of tuberculariza- tion, there is every reason to hope that we shall ultimately discover a rational and efficacious treatment of tubercles already deposited, espe- cially of the inflammatory complications. This, however, will become much less necessary as the experience of each shows, which there is every reason to believe it will, that these hypophosphorous remedies are also prophylactics to tuberculous diseases. 22 REPORT TO THE ACADEMY. The hypophosphites have a double action on the system : on the one hand they increase the principle, whatever it may be, which constitutes nervous force / on the other hand, they are the most powerful blood- generating agents, infinitely superior to any thing which we are now in the habit of employing. In consequence, it seems as if they could be employed to advantage in all those cases where it is wished to increase in the system either the one or the other of these two properties. These hypophosphorous preparations will occupy, without doubt, the most important place in the list of therapeutical remedies, as far as their powers of relieving nervous prostration, or any disturbance of the blood- generating processes are concerned. For this double character, they should be employed in nervous dis- eases, in cases of paralysis (where their use is not contra-indicated by the existence of congestion), in protracted convalescence, and in the adyna- mic period of acute diseases. It would be well to try them in the cold stage of cholera, and in the last stage of yellow fever, etc. It is time, gentlemen, that I should close my remarks. I am well aware how prone we are to deceive ourselves,—how easy and pleasant it is to be deceived,—as to the results of our own labors ; therefore, I do not hesitate to acknowledge the incompleteness of the paper which I have now the honor of presenting to you. I simply ask for it your consideration. It is the consciousness of its imperfections that has in- duced me to defer its presentation until this day. May it prove for the well-being of the human race and for the benefit of science, that your judgment, and that to be given by experience, shall confirm the results which I have announced. NOTES OF CASES SUBMITTED TO THIS TREATMENT FIKST SEBIES. CASES WHICH RESULTED FAVORABLY. CASE NO. I. Dona Isabel de S----, 16 years of age, born at Havana, unmarried. This pa- rent first consulted me in the month of April, 1854, complaining of a slight, though persistent cough, which had annoyed her for about two months, with perceptible .oss of flesh. There was a moderate expectoration of a limpid and transparent luid. There had never been any haemoptysis, but she had lost both appetite and Btrength. She was also troubled with excessive leucorrhoea. The quantity as well as the color of the catamenia had diminished at each of the last two menstrual periods. On examination, I found a decided rudeness of the respiratory murmur just be low tho right clavicle, with prolonged expiration, but no crepitation even during a cough, and without any diminution of the sound under percussion, and with very Blight vocal resonance. In the supra-scapular-fossa of the same side, there was merely a slight feebleness of the respiratory murmur. I ordered the treatment to consist of inhalation of air, charged with moisture by Us passage through water, in which had been dissolved a grain of atropine to each ounce, a system of treatment which I was experimenting upon at that time. In ad- dition to this, she was ordered a preparation of iron, a strengthening diet, consist- ing principally of roast meats and milk; walks early in the morning, and a resi- dence in the country. Under this regimen, but above all perhaps on account of the favorable weather, her appetite and strength returned; her catamenia increased both in abundance and color; the cough and expectoration ceased entirely; and the rudeness of the respiratory murmur at the apex of the left lung, gave place to the softness of the natural respiration. There remained, however, still a little dullness of the respiratory murmur in the supra-scapular-fossa. This favorable state of things continued during the whole summer and early part of the winter; but in the month of February, 1855, my patient commenced anew to cough, to grow thin, and to lose her strength and appetite. On the 4th of March, I made the following note of her condition: Countenance pale and de- jected ; well-marked loss of flesh; eyes languishing, and, as it were, swimming in moisture; cough frequent, especially in the night; slight expectoration of a trans- parent, but not mucous fluid ; no night sweats, but only a slight moisture of tho 24 NOTES OF CASES body when in bed; no fever in the evening; catamenia at the last period less abundant than usual; very little appetite; says she is very feeble, and appears anxious about her condition. On examination of the chest, I found in the right supra-scapular-fossa well-marked diminution of the respiratory murmur, but without crepitation or prolonged expir- ation. The resonance over the back was about the same on each side. In front, it seemed a little diminished under the right clavicle, where I also found a decided rudeness of the respiratory murmur, with slightly increased sound of the voice. The expiration over the same spot seemed notably prolonged. I recommended the former treatment, viz.: inhalation of atropine; iron reduced by hydrogen, one grain each day; roast meats and a milk diet, together with a moderate amount of exercise on foot each day. March 15th.—My patient does not find herself improved; her cough is more frequent, and fatigues her excessively; the moisture of the body at night has in- creased ; her appetite and strength have diminished still more. She was ordered to continue the same treatment, and in addition to take to-morrow morning as an emetic two grains of tartarized antimony, dissolved in three wine glasses of warm water, to be divided into three doses, and taken at intervals of a quarter of an hour. March 11th.—The emetic acted very powerfully; she rested better last night, and has coughed less. This morning she feels a little more appetite, but complains of a pain in her throat and a sensation of constriction over the whole chest; she is also, as she says, very weak. Continue the inhalations and the iron. March 18th.—Has passed a rather wakeful night; has coughed a little less than during the few preceding days, but has been grievously troubled with night sweats. She complains of being excessively weak, and has no appetite whatever; the ex- pectoration is a little more abundant; she still has the pains over the chest; the stools are natural; she has some little leucorrhcea. To continue the inhalations, and the iron increased to two grains each day. March 19th.—Still continues in the same condition; her strength is still more diminished, and she has perspired copiously during the past night. Auscultation shows the same signs as at the first examination; but there is some slight crepita- tion just below the right clavicle. The dullness seems to be more decided and ex- tended, and can now be found equally as well over the back. To continue the same treatment, and in addition to take each day a table spoonful of cod liver oil. March 20lh.—Condition as before—to continue the same treatment. March 2Gth.—Coughs very frequently, which prevents her from sleeping. I find her very much alarmed because she has seen a few streaks of blood in her expec- toration. Her catamenia, which have appeared within a few days, have been much less abundant than ordinary, and also deficient in the proper color; the leucor- rhcea has much increased; the night sweats continue excessive, especially about the head. Stop the iron, and take every day two table spoonfuls of cod liver oil. March 21 th.—Same condition. March 29th.—She has again raised blood, and this time in much greater quan- tity: in consequence, she is very much alarmed and dispirited; there are some mucous sputa in the midst of the limpid expectoration; the night sweats have been still more troublesome, and her cough fatigues her much during the night. WHICH RESULTED FAVORABLY. 25 Continue the same treatment, and order another emetic of antimony to-morrow morning. March Blst.—The paroxysms of vomiting have fatigued her very much; she com- plains more particularly of pains in the throat and chest, notwithstanding which she has slept better, and coughed less during the night The expectoration is more abundant, and the amount of mucous increased, but without any show of blood. April 1st.—Same condition: she complains of the sensation of constriction in the chest which the act of vomiting causes her; the perspiration was profuse last night; the expectoration contains a little more mucous; the cough still fatigues her very much, and she has very little appetite; her strength has diminished since the commencement of the preceding month. Continue the cod liver oil. April 3d.—There are still occasional streaks of blood in what she raises. Last evening she had a chill, followed by an increase of fever. She has perspired a great deal while sleeping, and the cough has kept her awake the greater part of the night. Continue the same treatment. April 4th.—Last evening she had another chill, followed by fever; the sweating has been excessive, especially about the head; there are some streaks of blood in the expectoration. The patient is greatly prostrated, sad, and dispirited, and has almost lost her appetite. Stop the cod liver oil. April 5th.—Made a careful examination of her case, and found the general condi- tion to be such as stated in the preceding notes. On percussion, I found a di- minished resonance below tho right clavicle over a space of three fingers breadth in width; the same condition was also found behind, but in a less decided degree. On the left side the resonance in front as well as behind seemed normal. Auscul- tation showed moist crepitation in the same region, which did not disappear while she coughed. Over the rest of the right lung the respiration was more increased than over the left. The voice seemed a little resonant, but only in a slight degree. The left lung shows nothing abnormal. Diagnosis.—Tubercles at the summit of the right lung at the stage of acute soft- ening. Encouraged by the trial on the subject of the twenty-first observation, I deter- mined to employ the hypophosphite of lime, and therefore ordered her, to-day, four grains of that salt April 6ih.—Last evening she had a slight chill, followed by heat, but she finds that she has coughed less and slept better; otherwise she is in the same condition, except that she seems a little less prostrated, arid there is no blood in the expec- toration. Treatment, five grains of the hypophosphite of lime. April 1th.—Last evening she had a slight sensation of cold, followed by heat. She says that she has perspired less, and slept better; she seems less sad, and the cough less frequent than day before yesterday. Her mother and sisters say that they think she has sensibly improved. Treatment, six grains of the hypophosphite of lime. April 8th.—My patient finds herself much better. She says that the night sweats have been less; that she has slept well; feels herself stronger; that her cough has much diminished, and that her appetite is improving. Treatment, seven grains of the hypophosphite of lime. 26 NOTES OF CASES April 9th.—Her countenance looks infinitely better; she is almost gay; saya that she has slept very well; that her cough awakened her only twice during the night; the expectoration is diminished, and contains only a few mucous clots, swimming in a transparent liquid, but without traces of blood. Treatment, eight grains of the hypophosphite of lime. April lOth.—Has sensibly improved; says that she perspires but very slightly; coughs very little, and sleeps well nights. This morning she went out of doors for a walk, and took breakfast with considerable zest. Gave nine grains of the hypo- phosphite of lime. April 11th.—Continues to improve. Ordered ten grains of the salt, to be con- tinued at that dose for the following days. April 15th.—My patient tell3 me that she does not sweat at all; that she coughs very little, and raises scarcely any thing. Her countenance has completely changed; her features have filled out; she is cheerful and animated. She has a good appe- tite ; her evacuations are natural, and the leucorrhcea has almost disappeared. April 26th.—Has continued to improve from day to day. "Within the past few days her catamenia have appeared as abundantly and naturally colored as before her sickness. During this period her cough has slightly increased, but her appetite and strength have continued good; the expectoration is very slight. The hypo- phosphite of lime has been taken every day since the last note, except yesterday and to-day. On examination, I found the crepitation at the summit of the right lung is much less than at the time of my last examination on the 5th of this month; it seems to me that the dullness has also diminished, and that the exaggerated respiratory murmur at the inferior portion of the lung has almost disappeared. April 21th.—Her cough has returned to what it was before the access of her catamenia. It consists of but little more than one or two coughs at morning and night. Ordered her to commence again with the hypophosphite at the dose of six grains. May 8th.—The treatment has been continued as at last date. Since the 1st of this month the dose of the medicine has been carried to ten grains. My patient would hardly be known for the same person, so much has she improved in the past month. Nearly all the general symptoms have disappeared, and nothing remains but a slight cough, principally in the morning, but without expectoration. She has nearly regained her usual amount of flesh, and her healthy appearance. Percussion shows that the dullness of the right side has nearly disappeared; the crepitation is very slight, as well in front as behind; she can take a long walk every morning without being in the slightest troubled for breath. Suspend treat- ment for two days. May 11th.—Same condition. Commence again with the salt at a dose of ten grains. May 25th.—My patient has not coughed any for the past fifteen days; there is no expectoration whatever; she is stouter than before her sickness, and says that she never felt so well in all her life. She now eats more than any other member of the family. Suspend treatment for two days. May 27 ih.—On examining my patient I find that the general symptoms have disappeared for the last fifteen days. As to the physical signs, I find still behind, WHICH RESULTED FAVORABLY. 27 in the right supra-scapular-fossa, little feebleness of tho respiratory murmur, espe- cially during inspiration; but the crepitation which was heard both in this region, and under the clavicle, has completely disappeared. Return to the former treatment, and take the salt in a dose of ten grains. This she continued until the 1st of June, when by my directions she went to reside in tho country. At the close of the month of June I saw her again; she was then fatter and in better health than she had ever been. Auscultation showed me no difference be- tween the right lung and the left. My patient continued to enjoy perfect health during the whole of the following winter. On my departure from Havana in April, 1856, she was making preparations for her marriage, and presented the appearance of the most perfect health. I made another examination at this time, and found the respiratory sounds natural on both sides. Any remarks upon this case will be superfluous: but I assure the reader that however much astonished or even skeptical he may be, he can not be more so than I was myself. I had evidently discovered, and had at my control, a new and powerful method of treatment. But I asked myself—will it fulfill all the indications which I wish from it—all which, at tho outset, it seems to promise me ? Perhaps I am only deceiving myself, and this result, which I have seen, is only the coincidence of a fortunate train of circumstances. We shall see, further, how well my other experiments answered these questions. CASE NO. II. Miss C----, six years and a half old, born in Canada, but living in Havana for the past two months, was brought to me for the first time on the 7th of February, 1856, by her mother, who gave me the following particulars: Her child commenced to cough in October of the year before; the cough was dry and recurred in paroxysms. At the same time she lost her appetite and flesh, and became much depressed in spirits. She was attended by an uncle, who ordered her cod liver oil and other remedies; but the cough, as well as the other symptoms, becoming more aggravated, he advised her parents to carry her to Havana, where they arrived in December. For a short time after her arrival, her cough seemed to mend, but the change was very slight. There had never been any expectoration. The child continued to grow weaker each day until her visit to me, when she could scarcely walk, and required to be held constantly in the arms of some one. She had almost wholly lost her appetite; complains much of her head, and says that it pains her in front; her disposition has become capricious and variable; she changes suddenly from sadness to laughter, and often bursts into fits of violent weeping; she perspires very freely, especially about the head and neck; she Bleeps badly at night, and in the morning will often start up suddenly, uttering piercing cries, after which she will relapse into a species of syncope, become quite 28 NOTES OF CASES pale and cold. This last phenomenon has only developed itself since her arrival at Havana, but within the past two weeks it has occurred four or five times. On examination, I found the abdomen neither tumefied nor tender on pressure. Latterly she has been almost constantly constipated, and only has an evacuation when she has taken a purgative of magnesia. The face of my little patient was pale and sad. Her eyes were preternaturally large and deep set, with a haggard, wild stare, and the pupils much dilated. She either heard with difficulty the questions which I put to her, or obstinately refused to answer. She told me that her head pained her, and carried her hand to her forehead to indicate the locality. Her mother stated that her skin was alternately burning and cold. I found it, by examination, warm. The pulse was 110. She has never passed any worms. On examining the chest, I found above and below the clavicle on the left side a sensible dullness, and over the same spot a marked diminution of the respiratory murmur, but no rales or crepitation; over the rest of that side, the respiration was slightly exaggerated; there was nothing peculiar in the cough or voice; on the right side resonance and the respiration appeared normal. Diagnosis.—Bronchial, and probably cerebral turbercular deposit. I commenced her treatment by ordering half a grain of the hypophosphite of lime. February 8th.—This morning she again awoke suddenly from her sleep, shriek- ing, after which she became pale and seemed to lose consciousness. I was sent for, but was out In other respects she remains the same. Continue the treatment. February 9th.—Yesterday she seemed less depressed, and passed a tranquil night. This morning she awoke quietly, and breakfasted better than usual. Or- dered the dose to be increased to three-fourths of a grain. February 10th.—Perspired less last night; awoke calmly; yesterday had a natural evacuation; her face is less haggard, her disposition less sullen than a few days ago. February 11th.—Coughed much less yesterday, and during the night perspired very little ; her appetite is better, she is stronger, and can even walk a little when earned into the open air. Increase the dose to one grain. February 13ih.—This morning she awoke suddenly, crying, and with a frightened air; after which she became pale, but did not lose consciousness. Condition about the same, but seems stronger. February 15th.—All her symptoms continue to amend; has nearly as good an appetite as before her sickness ; the cough has diminished; she has scarcely any night sweating, and does not now complain of her head. The treatment was sus- pended for two days. February 11th.—Continues to improve. This morning she started suddenly from her sleep with a frightened air, but did not cry out, and although she became slightly pale, did not lose consciousness. Dose reduced to three-fourths of a grain. February 18th.—Getting better and better; is quite lively, and laughs occasion- ally ; coughs very little, and has merely a moisture of the skin at night; has a natural evacuation nearly every day; walks about freely; she has filled out, lost that sad look, and from her appearance, would never be judged to have been sick. Increased the hypophosphite to one grain. March Uh.—The change in the appearance of the child is so great as to attract the attention of every one who saw her before the commencement of treatment WHICH RESULTED FAVORABLY. 29 All the symptoms—cough, sweating, feebleness, etc., have disappeared, and her mother says she has never seemed better in her life. From this time the dose of the salt was increased to a grain and a half each day. March 8th.—Examined her chest, and found still a little feebleness of the vesic ular breathing at the apex of the left lung; but the resonance, on percussion, seemed to me about equal on each side. Suspended the treatment for two days. March 10th.—[The patient was attacked with a severe dysentery, from over- indulgence in fruit, and a cold taken during the night. Under proper treatment, during which the hypophosphites were discontinued, she recovered in a few days.] —Trans. March lith.—Says she is well and wishes to get up. Yesterday had a natural evacuation; no pain over abdomen; no fever; pulse 100. Gave soup, and rice and milk. March 16th.—Sleeps well; does not cough, and has no sweating. March 11 ih.—Auscultation shows still a little feebleness of the respiratory mur- mur at the apex of left lung. Resonance equal on the two sides. Commenced again the use of the hypophosphites at a dose of three-fourths of a grain, which I increased by the addition of a quarter of a grain each day until I had reached two grains. March 22d.—Seems perfectly well. Her mother assures me that she has never seemed so strong and lively since she was born. Her appetite is excellent. By auscultation I found still a little feebleness of the respiratory murmur at the apex of the left lung; but much less than a short time ago, and perhaps not more than the normal difference between the two sides. The treatment was continued up to the 26th of the month. I did not see her after this, because, being necessary for me to leave the city, her mother decided on returning to New York. I have had no further tidings from her. CASE NO. III. Don F----P----: 42 years old ; native of Havana. This gentleman, whom I havo been attending nearly a year, visited me on tho 9th of June, 1855. He has suffered for several years. There is a large-sized cavity occupying nearly two- thirds of the left lung, surrounded, especially at its inferior side, with tubercles in process of softening. The disease has been slow, but constant, in its progress. The weakness, diffi- culty of breathing, cough, and expectoration, have little by little increased. I have tried various remedies in his case, but without obtaining any satisfactory result. The treatment from which he has seemed to derive the most relief, and has been employed the longest, consists of inhalations of atropine, after the plan spoken of in the first case, with small doses of iron and the tincture of digitalis. He has taken at various times cod liver oil, as well by my direction, as before his coming to me, by advice of ono of my friends; but the use of this occasioned, after a short time, severe hemoptysis, which compelled him to discontinue it I wish here to state that this remedy has never seemed to produce, in warm climates, 30 NOTESOFCASES any advantageous effects which I have sometimes observed from its use in Europe. Few persons can continue its use beyond a few days,—it often causing either se- vere hemoptysis, or such a trouble in the intestinal canal as to forbid its use. I am satisfied, by repeated trials, that these phenomena do not, in the slightest de- gree, depend upon the character of the oil used. Encouraged by the results of the use of the hypophosphites in the other cases, I finally decided to employ them in this case also. The conditiou of the patient is now as follows:—Great emaciation; his face pale and peaked; considerable weak- ness ; bad appetite; digestion slow and laborious; no diarrhoea; cough frequent and annoying, often preventing his sleeping at night; expectoration muco-purulent and copious enough to three-quarters fill a tumbler in twenty-four hours. Has night sweats, especially over chest and neck; is obliged to sleep mainly upon the right side, as he cannot rest at all upon the left, nor remain upon his back longer than a few moments. Nearly every three or four weeks he has a more or less profuse hemorrhage lasting four or five days; the two last times to an alarming extent. He was formerly troubled with hemorrhoids, but they have disappeared for the past three years. On auscultation, I discovered the following conditions:—On the right side, both in front and behind, the resonance and the respiration were about normal, though the latter may have been slightly increased. On the left side, and at about an inch below the clavicle, there was a decided diminution of resonance. Over the same spot there was moist crepitation, and lower down a cavernous r&le and pectorilo- quy. Sound of the heart increased, but with nothing abnormal about it. Behind, in both scapular-fossae, there were marked cavernous rales, with great vocal reso- nance. The resonance, on percussion, seemed about the same as upon the right side. Behind, the respiration was increased at the base of the left lung. Ordered him to take four grains of hypophosphite of lime, which was to be increased each day after by one grain. June \5th.—My patient feels stronger; has more appetite; slept last night upou his back, and for a short time upon his left side. Ordered the dose increased to ten grains. June 20th.—Is decidedly improved, and although very thin, has lost his appear- ance of suffering and prostration. His appetite, he says, is better that it ever was before; has no night sweats; sleeps as he pleases, upon his back, or either side; coughs much more rarely; the expectoration has diminished more than a half, and is more transparent Suspended the treatment for two days. June 30th.—Commenced the use of the hypophosphite on the 23d, at the dose of six grains. Yesterday he had a slight hemoptysis, it being about the time it has usually occurred. In consequence, I suspended the treatment. The hemorrhage was merely a few striae of blood in the matter expectorated, but my patient is much alarmed, as the last one was so profuse. In order to tranquillize him, I or- dered ten drops of the ethereal tincture of digitalis three times a day. July 2d.—The hemorrhage has ceased, and the patient continues to improve. By auscultation, I found the mucous r&les much less abundant, and mixed with sibilant rhonchua There is also a slight sound, as of friction at some distance. WHICH RESLLTED FAVORABLY. 31 July 3d.—Ordered the dose at six grains. July 18lh.—My patient feels better than at any period since the commencement of his illness. He coughs and raises very little; has no sweating; has a good appetite, and is much stronger. Suspended treatment for two days, and then commenced with the dose at six grains, which was gradually increased to ten. July 20th.—My patient says that he passed a little blood yesterday at stool. In- creased the dose to fifteen grains. August 3d.—Lost more blood yesterday. Ordered the salt at the dose of twenty grains. August 4lh.—The hemorrhoids bled again yesterday. They protrude and trouble him very much. Suspended treatment, and ordered an injection of infusion of rhatany. August 5th.—Bleeding has diminished. August 6th.—Bleeding has ceased. August 10th.—Commenced with the hypophosphite at six grains, which was in- creased by a grain a day to ten grains. August l±ih.—Discovered, by examination, the following condition:—On the right side, the resonance and respiration perfectly normal. On the left, marked dullness below the clavicle, over a space of an inch in width. Over the same spot, intense cavernous respiration, pectoriloquy, a sound of dry rubbing, but no rdles. On the back, in the supra-scapular-fossae, the same cavernous respiration, but more distant from the ear than in front. There is resonance of the voice, but no crepi- tation. September 25th.—Continued the treatment steadily up to this time. My patient ha3 gained flesh, although still quite thin; his appetite and strength are good; has had no more hemoptysis, and has only one slight coughing fit in the morning, and raises a little transparent mucous; sleeps well on either side, or upon the back. Auscultation shows in front, in the upper part of the left lung, intense cavernous respiration, with pectoriloquy, but no r&les or crepitation. Behind, the same phe- nomena is manifested, but less marked ; over the rest of that side, the respiration is slightly rude. The right side seems normal. My patient passed tho following winter with no perceptible change. He was attacked with a slight bronchitis, which seemed to have its location in the cavity and base of the left lung. Since sibilant and ronchus rales were heard there, I continued an expectorant treatment, and in the course of about two weeks it wholly disappeared. In March, 1856, I examined him anew, and found the lungs in the same condition. Since then he has written to inform me that his health remains unchanged. CASE NO. IV. Don Juan C----; 29 years old; born in Havana, married. November 6ik, 1855.—This gentleman called upon me for a slight spitting of blood, which he has noticed for the past three weeks. About a fortnight before 32 NOTES OF CASES this hemorrhage, he commenced to cough; has also lo3t strength and appetite, and sweats much at night. Two sisters have died of consumption. On examination, I found the following to be his condition: Nothing peculiar in his general appearance; his cough is quite troublesome; the expectoration slight, containing some mucous and a quantity of blood, sufficient, perhaps, to fill half a wine-glass in the course of the day. He is very feeble, so that he has not been able for the past three weeks to go out to attend to his business. The resonance, on percussion, is about equal on the two sides, as well in front as behind, but perhaps slightly diminished in the left supra-scapular-fossa. By auscultation, I found at the apex of the left lung, both in front and behind, moist crepitation which did not disappear when coughing. At the lower front por- tion of the same lung, the respiration was increased in a marked degree. Nothing peculiar in the sound of the heart. The respiration was normal over the right side. Diagnosis.—Tubercles at the apex of the left lung, commencing to soften. Ordered at once six grains of the hypophosphite of lime and sulphuric acid in sweetened ice water. November 1th.—A few streaks of blood only in the sputa.; complains of colic having troubled him in the night. Suspended the acid and ice; gave eight grains of the hypophosphite of lime. November 8th.—Coughs, sweats, and raises less. Gave ten grains of the hypo- phosphite. November 2Uh.—My patient attends to all his out-door affairs; feels as well as ever; has a good appetite; no sweating; coughs and raises very little. Suspended treatment for two days. November 28th.—Commenced the treatment in a dose of ten grains. Examined his chest, and found the crepitation much diminished; the other signs as at the first examination. January loth, 1856.—At the examination, with my utmost care, I could discover no difference between the two lungs. The respiration seemed as normal on the left as on the right side. My patient continued perfectly well up to the time of my departure, three months afterwards. CASE NO. V. Maria R----: a negress; 19 years old ; Unmarried; free, ana supporting herself by washing. January 2d, 1856.—This patient came to consult me for a cough which she has had for about three weeks. During this time she has lost much flesh, and become so very weak that she has been compelled to stop washing; she has fever at night, and sweats a great deal, especially about the head. At the last period, menstrua- tion was much less abundant than natural; she has very little appetite, but no diarrhoea ; the cough is frequent and dry ; what little is raised, consists of a clear fluid, entirely salivary in appearance, .with no trace of mucous; she is so troubled in breathing that she can scarcely walk. Her face, and especially her general appearance, presents in a high degree that WHICH RESULTED FAVORABLY. 33 look which seems to be a peculiarity of all consumptives, but which is much more striking in colored people than the whites. On examining her chest, I found over the front of the left side, a diminution of resonance under the clavicle, and at the same point a marked rudeness of the respiratory murmur, with marked resonance of the voice. Behind, in the left supra-scapular-fossa, dry crepitation, especially perceptible at a deep inspiration. These signs, added to the severity of the general symptoms, enabled me to form, without difficulty, the following diagnosis: Tubercles deposited at the apex of the left lung, just commencing to soften. Ordered immediately eight grains of the hypophosphite of lime. January 3d.—Feels better and coughs less. Increased the dose to ten grains. January 4th.—Less fever and sweating last night; thi3 morning has a little appetite. Gave twelve grains of tho hypophosphite. January 5th.—Night sweats still more diminished and cough lighter; this morning feels stronger, with better appetite. Ordered fifteen grains of the salt January 13th.—She informs me to-day that the night sweats have ceased, that she eats well, and feels sufficiently strong to again commence work; she coughs very little: requested her to remain quiet for a short time longer. I found, on examination, a little dullness under the left clavicle, and marked rudeness of the respiratory murmur, although it seems to me much improved. There is still resonance of the voice. Tho crepitation which I had noticed over the back has disappeared. Suspended treatment for two days, when it was again commenced with tho dose at ten grains. February 2d.—Has been working for the past two days; has no cough; hai gained flesh and strength; has no shortness of breath, even when working hard, her catamenia have become as profuse as natural. I found, by auscultation, th« respiration on the left side almost normal, but on percussion, still a little dullness below the left clavicle, with slight vocal resonance. Increased the dose to fifteen grains, at which it was kept until February 20.—When an examination showed no perceptible difference between the two sides. I then ceased my visits. March 12th.—Has returned, because she has been troubled for the past four or five days with very slight sweating: she also coughs a little; otherwise ia well. Found on examination a few sibilant rales over both lungs. Ordered some Blight remedies, and by the 22d all the symptoms had disappeared. April 3d.—A few days before my departure I visited her, and found her per- fectly well. CASE NO. VI. Mr. M----: 22 years old; born in the United States; unmarried. March 15th, 1856.—The patient gave me the following history: Commenced coughing in October last; in November he raised, for several consecutive days, a quantity of blood; has taken various remedies without relief. In January, by the advice of his physician, he came to Havana for the benefit of a change of climate, but has experienced no improvement from it; has become more emaciated 3 34 NOTES OF CASE S since his arrival, and completely lost his appetite. His mother died of consump- tion. His present condition is as follows: Moderate degree of emaciation; face pale; great weakness and depression of spirits; cough frequent, especially nights and mornings; sweats at night, principally about the neck and chest. Expectoration is slight, and composed of perhaps a dozen muco-purulent sputa; has little appetite; digestion good; evacuations natural; gets out of breath easily, especially while walking, or going up stairs. Percussion of the chest showed a diminished resonance on the left side, extend- ing from the clavicle to the level of the fourth rib, but most perceptible below the clavicle. Behind there is dullness, principally in the supra-scapular-fossa. On the right side the resonance was normal. Auscultation showed on the left side, in front, great feebleness of the respiratory murmur. Under the clavicle, for a space of the width of a finger, there was none whatever. Behind, on the same side, in the supra-scapular-fossa, especially upon its inner side, there was moist crepitation; in the sub-scapular-fossa, it also ex- isted, but slighter; the respiratory murmur was quite feeble at the base of the lung; the respiration, both in front and behind, was much increased over the right side, which seemed normal. I noticed over every part of the left lung great weakness of the respiratory mur- mur, as well as increased resonance of the voice; but this was much less in degree than I expected. The sounds of the heart were somewhat stronger, but otherwise offered nothing peculiar. Diagnosis.—Tubercles in the first and second stages, occupying a great extent of the left lung. At this time I had but a small amount of the hypophosphite of lime left, and as I was intending to leave for Europe in fifteen days, I was forced to order a con- tinuance of the treatment prescribed by his physician in the United States; at the same time, giving him every degree of encouragement in regard to his case. On my explaining the reasons which called me to Europe, the parents of the patient decided to accompany me there, in order that he might continue my treatment. On his arrival at Paris, on the 10th of May, he was in the following state: The crepitation increased in the sub-scapular-fossa; the general constitutional disturbance greater; cough worse, and expectoration more abundant, with night sweats. Emaciation had advanced rapidly, and he had become very feeble and despondent. Commenced with the hypophosphite of lime at the dose of ten grains. May 11th.—Increased to twelve grains. May 12th.—Cough, expectoration, and night sweats lessened. Increased to fifteen grains. May 30th.—The treatment has been continued at the same dose. There is now no expectoration whatever, and but little cough in the morning; no sweating; a good appetite; strength and spirits completely restored. His lineaments have changed so completely, that he would scarcely be known for the same person. From being pale, he has acquired a full, fresh color. His chest shows the same signs as at the commencement of the month, except that the crepitation has diminished in the sub-scapular-fossa. WHICH RESULTED FAVORABLY. 35 Suspended treatment to June 4tb, and then commenced again with the dose of twelve grains. June 19th.—Patient has not coughed for the past fifteen days; raises in the morning a mucous clot, not larger than a filbert; was never stronger than at pres- ent ; is still short-winded, but much less so than at first; has gained flesh. Found, on examination, the crepitation of the sub-scapular-fossa had completely disappeared, but that a httle still remained in the supra-scapular-fossa. Respiration on the right side is heard better, both in front and behind; there is yet a differ- ence in regard to the left side, especially below the clavicle, but it can be heard everywhere. The treatment was suspended for four days, and then again commenced at the dose of twelve grains, which was successively increased, two grains at a time, until twenty grains were given. August 9th.—Find a sensible alleviation of the local symptoms; the constitu- tional ones having long since disappeared. The respiration is heard better over the whole lung. In the Bub-scapular-fossa but slight crepitation can be heard, and that only under the influence of forced inspirations. Under the left clavicle, the respira- tion has always been more feeble than on the right side. Suspended treatment for six days and then commenced again with fifteen grains. August 30th.—All crepitation has disappeared in the left supra-scapular-fossa; and upon the inner side, where it was heard most freely, it sounds as if there was a slight cavity; no vocal resonance; no cough whatever; the patient can take long walks without inconvenience. From this cause, and for certain other reasons, all treatment was suspended until October 28th.—The patient seems about the same, except that he has lost his appetite a httle. Commenced the treatment again with a dose of ten grains. November 4th.—General health good; still feebleness of the respiratory murmur, below the left clavicle; no crepitation over the back; no cough or expectoration. Increased tho dose to twenty grains. December 14th.—Found, on examination to-day, no difference between the two sides, unless it might be a slight diminution of the respiratory murmur, below tho left clavicle ; no vocal resonance. Up to this time, he did hot seem to have been affected by the cold. I wished him to pass the winter at Paris, in order to test the permanence of his cure, but be preferred going to Egypt He left in a few days, and since then I have not heard from him. CASE NO. VII. Victorine J----: 25 years old ; boot-stitcher; born at Melun; but has lived at Paris for the past twelve years; unmarried. November 24th, 1856.—Catamenia regular, but less abundant at the last period than ordinarily; has had a cough every winter for the past six years, but none in summer until the three past ones; once raised blood which continued a month. One of her sisters died of consumption, at the age of 14 ; now coughs a great 36 NOTES OF CASES deal, so as often to cause vomiting; raises a little mucous, but no blood; has pro- fuse night sweats; is too short-winded to walk, and at the slightest exertion her heart palpitates violently; Is troubled with constipation; has little appetite; sleeps badly; is emaciated ; and her face is sunken and pallid, but with a hectic flush. Nothing abnormal, either in front or behind, was discovered on percussion. The respiration over the whole of the right lung is more feeble than on the left side. At the base there is slight crepitation; over the inferior third of the lung, behind, the moist crepitation is well defined, especially during a cough; but there is no re- sonance of the voice. The diagnosis in this case offered some doubta The moist crepitation was lim- ited to the base of the right lung, but then there was a great diminution of the re- spiratory murmur, both in expiration and inspiration, over the whole of it; and there were no sibilant rales. On the other hand, although there had been no hemoptysis for some time, the intensity of the constitutional symptoms, their rapid aggravation, the loss of strength and appetite, the state of anaemia which had super- vened in so short a time, and the copious night sweats, could none of them, in my estimation, be attributed to a simple bronchitis. Her own antecedents, and those of her family, were also in favor of the existence of tubercles, in the first stage, at the summit of the right lung, with congestion of the base. Ordered the patient to take ten grains of the hypophosphite of soda. December 15th.—All the constitutional symptoms have disappeared. No crepi- tation can be heard, but the respiration is still feeble in front, under the clavicle. December 20th.—Has returned to work. Catamenia natural. January 12th.—Examination show3 no difference between the two sides. Says she feels better than ever before. Have not seen her since the last date. Judged by itself, this case would be of little value; but taking into consideration the antecedents, I think lam borne out in the diagnosis made: nevertheless, I give it with the greatest reserve. CASE NO. VIII. Joseph Coupier: optician; 26 years old; born at Montmartre; living in Paris; unmarried. Entered La Charite under M. Charles Bernard, June 21st, 1856. The* patient says his parents are alive and well; states that fifteen days before his en- trance he began to cough, and feel weak and short of breath; was troubled with a constant headache, with bleeding at the nose; has lost flesh enormously; no appetite; sweats at night. On the eighth day after the commencement of these symptoms, he began to raise blood, which continued for five days. Since his entrance into the hospital, the hemorrhage has never been suspended for eight consecutive days, and he has become still weaker; is covered at night with a cold perspiration, especially on the chest and hands. The treatment prescribed by M. Bernard consisted of cod liver oil, with opiates and astringents. Under this his appetite slightly improved. August 9th.—Examination shows dullness under the right clavicle, for a space WHICH RESULTED FAVORABLY. 37 of about an inch. Respiration on the same spot is a httle more feeble than on the right side. Under the inner side of the supra-scapular-fossa there is dullness, and some pain from the percussion. At the same point the ear can detect moist crepitation, and rude respiration; also great resonance of the voice. On the left side of the back, at tho apex of the lung, the expiration is prolonged, and in the sub-scapular-fossa there is moist crepitation. Over the rest of the lung the voice and respiration are normal Pulse 76 ; respiration 20. Diagnosis.—Tubercles in the first and second stages at the apex of the right lung; and probably tubercles at the apex of the left lung. August \0th.—The hemorrhage, at about two drachms each day, continues." Commenced with the hypophosphite of soda, in a dose of four grains. August 11th.—Increased the dose to ten grains. August 14th.—Have been myself sick for the past two days, so that the treat- ment was suspended. On the night of the 12th, a most violent hemorrhage set in, which has continued up to this time. I judged it prudent, therefore, to suspend the administration of the hypophosphite, not because I thought it dangerous,—for I believe it useful, in doses of four grains, in arresting the bleeding—but on account of the great responsibility in case it should happen to terminate fatally. He was ordered ice, astringents, etc. August 19th.—Only a few striae of blood now observable in his sputa. Last evening, he complained of a sharp pain in the right knee, which is excessively sensitive to the touch, especially over the internal ligament There is, however, neither redness nor swelling. Pulse 72 ; respiration 32. August 28th.—Before commencing the treatment again, M. Bernard examined the patient with me. I copy the notes made by the assistant, M. Guillot:— Pulse 72; respiration 32. Mucous expectoration, but not very abundant; is very weak; has not been able to raise himself for two days; cannot sleep nights; sweats excessively, especially about the head and neck; has very little appetite; tongue natural; no diarrhoea; has one evacuation each day; rests upon the right side, from inability to lie upon the other. The physical signs are: dullness under the right clavicle, with great rudeness of the respiration; moist crepitation over the two lower thirds of the lung, espe- cially after a cough; marked resonance of the voice; rudeness of respiration over nearly the whole of the left lung, with crepitation, but less marked than on the right side; diminution of resonance, on percussion, over nearly the whole of the right side of the back, particularly in both scapular-fossae, with moist crepitation. This, which exists also along the spinal column, is especially noticeable after a cough. Under the axilla it is even more decided, so as to approach to a fine sub- crepitant rale. The respiration is rude over the whole of the left lung, but par- ticularly in the sub-scapular-fossa. In the supra-scapular-fossa there is some crepitation. By this it will be seen that the disease has made rapid progress since the 9th. Ordered five grains of the hypophosphite of soda. September 1st.—Feels stronger, sweats less, and has a better appetite. Pulse 60, perspiration 24 Gave five grains of the hypophosphite of soda. September 2d.—Increased the dose to eight grains. 38 NOTES OF CASES September 3d.—Increased to ten grains. September 6th.—Has been constantly improving; the cough and expectoration have almost disappeared; there is no sweating; he sleeps and eats well; is getting Btronger, and can rest well on his left side. Increased the dose to fourteen grains. September 9th.—Continues to improve, but complains of a severe pain in the supra-scapular-fossa, on bending his body. Reduced the dose to ten grains. September 13th.—Increased to twelve grains. September \4th.—Says that he ate some cabbage, which disagreed with him; rose from bed, but felt so cold that he was obliged to return to it. Reduced the dose to ten grains. September 15th.—Increased the dose to sixteen grains. September 16th.—Ordered twenty grains. September 19th.—Says that his hair has been falling out very much for the last three weeks. Suspended the treatment. September 21st.—Ordered five grains of the hypophosphite to be given. September 23d.—Asked permission to go out for a walk. September 24th.—Walked more than a mile yesterday. September 25th.—At my request, M. Bernard made a second examination with the following results: Diminution of resonance on percussion, under the right clavicle, for a distance of more than an inch; rude respiration, with vocal reso- nance in the same place, but no crepitation; lower down there is a spot where there is diminution in vesicular breathing, but no crepitation. On the left side there is some rudeness of the respiratory murmur ; the resonance over the back on percussion, is about equal on the two sides. On the right side, in both scapular- fossae, there is slight feebleness of the respiratory murmur, but no crepitation or resonance of the voice. It will be seen by this condition of the patient what a change for the better there has taken place since the commencement of treatment. Ordered five grains of the hypophosphite. September 30th.—For the past two days he has coughed more; last night the attendant found him feverish; with a pulse at 96; with mucous rales over the su- perior third of the right lung. Gave eight grains of the hypophosphite. October 2d.—Less fever; is otherwise improving. October 4th.—Was obliged to suspend treatment upon all the patients confided to me by M. Bernard. October 8th.—An examination was to-day made by M. Axenfeld, who forwarded me his result, viz.: some crepitation on the right side in front; behind it is more marked, and almost reaching a cavernous rale; over the same point there i3 diminished resonance of the voice. October 16th.—The patient entered the hospital St. Louis, under the charge of M. Briquet. He states that since giving up my treatment he has lost flesh and appetite, and has sweated and coughed more. He was examined by M. Briquet, who found the following symptoms: in both scapular-fossae, on the right side, gurgling; a little cavernous respiration, and dull- ness. Nothing abnormal on the right side, in front. The left lung seemed healthy, both over the front and back Ordered ten grains of the hypophosphite of lime. WHICH RESULTED FAVORABLY. 39 October 11th.—Increased it to twelve grains. October 20lh.—Has been steadily improving. Decreased the dose to eight grains. October 23d.—Pain and difficulty in breathing in the left supra-scapular-fossa. Omitted treatment. October 24th.—Says the pain is greater. Ordered eight grains of tho hypophos- phite to be given. October 25th.—Says the pain has been so great that he could not sleep, and has been obliged to sit erect all night: otherwise feels well enough to work. This I recommended him to do, for I suspected that his pain arose from a state of pleth- ora, and that it would be dissipated by exercise: a fact which I had noticed in several other cases. October 30th.—Having left the hospital he walked to my house to visit me. Gave eight grains of the salt. November 6tli,—The plethora, or fullness (dyspnoea) has disappeared for several days. Cough is much less; no expectoration; appetite good; no sweating, and has gained flesh. Increased the dose to twenty grains. November 1th.—Says he has rambling pains over the whole body. Suspended treatment November 11th.—Was obliged to call upon him, as he could not leave his house. Found sub-acute rheumatism in both knees. There was swelling, redness, pain to the touch, high fever, with a foul tongue. November 25th.—Has recovered, under treatment, from his rheumatism. Ordered ten grains of the hypophosphite to be given. November 28th.—Coughed and perspired a great deal last night. Changed to twelve grains of the hypophosphite of soda. November 29th.—Ordered twenty grains of the same salt December 2d.—Was obliged, from causes independent of his sickness, to suspend treatment. December 6th.—Gave twenty grains of the hypophosphite. January 10th.—Before leaving Paris I made another exammation, and found his condition as follows: Some difference in the" respiratory murmur under the left clavicle from that on right side; but this is scarcely greater than is often found in the normal state. With this exception, no one could tell which of the lungs had been affected. The respiratory murmur and resonance were everywhere normal The patient is in better flesh than ever before, has gained his full strength, can take long walks without fatigue, and mount to his room in the sixth story without loss of breath. This case seems to me not only one of the most remarkable, but also the most important, from the fact of the symptoms having been satisfactorily determined before the commencement of treatment, by several persons, none of whom were in favor of my method. The rapid progress of the disease; the sudden arrest of all the symptoms under the treatment; their commencement on its suspension, and their eudden disappearance when it had been again renewed; the attack of acute rheu- matism, all certainly showed some active agency in the treatment. Besides, the patient was in the best state to show the effects of this therapeutic agent The disease was just commencing, and although acute, had produced no permanent di3- turbanca The constitutional symptoms were intense, yet there appeared to be 40 NOTES OF CASES no complications; and lastly there was no uncertainty in the diagnosis. I now regret exceedingly not having remained at Paris a month longer, in order to havo shown the change to those who had seen him when first treated. I can not say whether he is now well, or had a relapse during the following winter: for notwith- standing he might be looked upon as cured, I think it was important to watch over his health, and for several months afterwards to occasionally continue the use of the remedy. CASE NO. IX. Eugene Maitre: 17 years old; jeweler's apprentice; unmarried; living inPari3; entered La Charite, June 22d, 1856. His mother, whose case is given at No. 15, has had her lungs affected ever since his birth. Three months ago, after catching cold, he began to cough and raise blood in small quantities. About a fortnight ago he had an attack of fever which lasted for twenty-four hours without cessation. Since then he has lost flesh, strength, and appetite, and perspires much at night; raises very little, and has no diarrhoea. At first he was placed by M. Bernard upon a treatment of cod liver oil, under which he seemed to improve. July 4th.—The following is the present condition of the patient: Feeble, lym- phatic constitution; not much cough or expectoration; night sweats; no fever; appetite and digestion good; diminution of resonance on percussion under the right clavicle; on the left side it is normal; on the right side, in front, the respira- tion is feeble over the whole lung, with considerable vocal resonance, especially below the clavicle; on the left side respiration is increased and the voice normal. Over the whole of the right back, there is notable dullness; the respiration ia quite feeble in the supra-scapular-fossa, with moist crepitation ; over the rest of the lung the respiration is feeble, and the voice resonant; over the left back, the re- spiration and resonance seem about normal. Diagnosis.—Tubercular infiltration, in the first stage, of the whole right lung, with induration of its tissues: commencement of softening at the apex. These symptoms, and the diagnosis, were confirmed by MM. Charles Bernard, Brochin, and Lebled. M. Bernard added, that the intensity of the vocal resonance made him suspect a cavity at the level of the spine of the scapula. July 5ih.—Commenced the treatment by ordering eight grains of the hypophos- phite of lime. July 6th.—Increased to ten grains. To-day M. Empis examined the patient and formed the same diagnosis. July 8th.—Gave fourteen grains. July 9th.—Increased the dose to fifteen grains. July 10th.—Increased to twenty grains. July 30th.—The patient has been steadily improving; no cough or expectoration. Changed the hypophosphite, and ordered twenty grains of the soda salt. August 6th.—M. Bernard examined the patient and found all the constitutional symptoms dissipated. Under the right clavicle a little more dullness was perceived WHICH RESULTED FAVORABLY. 41 than on the right side; the respiration in front about equal on the two sides; slightly greater resonance of the voice on the right side; over the left back, slightly increased respiration, and also of crepitation in the supra-scapular-fossa; elsewhere the respiration normal; some vocal resonance on a level with the spine of the scapula. In consequence of these ameliorations, he acknowledged that the patient showed a notable change for the better. August 18th.—Left the hospital and went to work. August 19th.—Suspended the treatment. September 1st.—Commenced again with ten grains of the hypophosphite oi lime. September 1th.—Suspended the treatment for eight days. September 22d.—Continues to improve. Ordered twenty grains of the hypo- phosphite of soda. September 29th.—Suspended treatment. October 1st.—Ordered eight grains of the hypophosphite of lime. October 6th.—No treatment. October 8th.—Gave twelve grains of the hypophosphite of lime. October 16th.—The patient was examined by M. Bernard, who found, at the right apex, in front, a decided vocal resonance, with slightly prolonged expiration; nothing abnormal over the back; over the left front, respiration normal, but be- hind he thought he discovered slight crepitation, which neither I nor M. Potain were able to hear. It is possible that the excitement of the patient may have in- fluenced, in some degree, the respiration. Continued tho treatment for the sake of security, and gave eight grains of the nypophosphite of lime. October 18th.—Have just learned from tho father of my patient, who is himself consumptive, that his brother died of phthsis eighteen months ago; that his wife has coughed for ten years, and that her mother died of consumption. November 21th.—Examined the patient, and could discover no difference between the two sides either by percussion or auscultation. Stopped treatment. In January, a few days before my departure from Paris, I saw the patient again, and found a complete absence of all signs of consumption. As to his general health, it not only seems to be perfectly good, but in appearance he is robust, and of a ruddy countenance. 42 NOTES OF CASES SECOND SERIES, CASES IN WHICH THERE WAS AN ALLEVIATION, BUT NO DECIDED RESULT, IN CONSEQUENCE OF CESSATION OF TREATMENT. CASE NO. X. Mrs. T------: 26 years old; born in the United States, but living in Cuba for the past year; husband is living. March 6th, 1855.—This lady has been sick for the past eighteen months. At the outset, she began to cough, and once or twice raised blood. She has lost flesh, strength, and appetite. She was recommended to go to a warm climate, and came to Havana, where she has been living in the vicinity until a month ago. There has been no perceptible change for the better since her arrival. None of her family have been consumptive. For the past six months her cough has increased, the expectoration become more abundant; the sweating is profuse, especially about the head and neck; her cata- menia have been suspended for four months. I now find the following to be her condition: Muco-purulent expectoration, com- posed of a transparent fluid in which there are yellow lumps of mucous, some of which sink to the bottom in a vessel of water; great debility, and emaciation; very little appetite; bowels constipated; the face pale and sharp; the eyes hollow; the attitude peculiarly characteristic. By percussion, I discovered a decided difference between the two sub-clavicular regions; the sound is the clearest on the left side, behind; the resonance is about equal on the two sides. Auscultation showed moist crepitation, occupying the superior third of the right lung, both in front and back; over the rest of that side great exaggeration of the respiratory murmur, especially marked in front, with decided resonance of the voice; on the left side, both under the clavicle and in the supra-scapular-fossa, there was also crepitation, but no vocal resonance. Diagnosis.—Tubercles in the second stage, at the summit of both lungs, far ad- vanced in softening, especially on the right side. The patient has taken cod liver oil several times, but with no decided benefit. I also ordered it, but in a few days was obliged to discontinue its use, as it was so repugnant to her. I then tried a variety of remedies, such as inhalations of iodine, atropine, the alkaline carbonates, and sulphuret of lime, none of which seemed to produce the slightest good. For a few days the bicarbonate of potassa seemed to diminish the cough, but it occasioned such a diarrhoea that I was obliged to dis- pense with its use. April 28th, 1855.—Commenced with four grains of the hypophosphite of lime, WITHOUT DECIDED RESULT. 43 April 30th.—Patient says she sleeps better, her appetite is improved, Mid she coughs less. Increased the dose to six grains. May 3d.—Has been riding out for two days past; is much stronger; has a good appetite; sweats very httle. For two days past she has had a regular evacua- tion. May 15lh.—Increased the dose to ten grains. All the constitutional symptoms have disappeared; the appearance of the patient has changed, so that she would scarcely bo known; there are no night sweats; the cough has diminished, as well as the expectoration ; the appetite and strength are good, and the bowels regular. May 29th.—The improvement has continued to this time. Fearing to remain through the summer, on account of the yellow fever, and feeling, besides, almost well, she has decided, against my earnest wishes, to return to the United States. Examination shows less crepitation on the right side; under the left clavicle it has entirely disappeared, but can still be heard in the supra-scapular-fossa. What would have been the final result of this case ? I have no hesitation in be- lieving that had she remained at Havana, the tubercles would have been slowly eliminated, and that perhaps she would have entirely recovered. I have had nc news from her; but I fear that the change of climate, and suspension of treatment, have induced afresh the symptoms which were disappearing, and that the diseasa followed its fatal course. CASE NO. XI. Don Carlos B----.: 42 years old; born at Havana; married. His disease com menced four years ago, during the winter, with cough, and slight bloody expecto- rations. Since then it has slowly, but surely, progressed. He was attended by me during several months, two years ago, at which time I found several tuberclei at the summit of the left lung, slowly softening; emphysema at the base of th« same lung, with contraction of the aortic orifice. June 5th. 1855.—The patient tells me that his strength has been constantly diminishing, the cough is more frequent, and that he has paroxysms of asthma nearly every night; he is very short of breath when he walks, so that he has been compelled to give up his employment; has not had any hemoptysis since the out- Bet, but has lost much flesh, and his appetite entirely; ho perspires at night, prin- cipally about the head and neck; the expectoration is muco-purulent, in great quantity, and mixed with much bronchial sputa. His appearance is that of a man attacked with severe heart disease. He if emaciated; his eyes are hollow; his lips purple, and his breathing anxious and noisy. Percussion shows dullness over the upper third of the right lung, both in fronj and behind. Below this spot, the resonance is, on the other hand, increased, and the same idiosyncracy exists over the whole of the left side. By auscultation, I found, below the right clavicle, and in both scapular-fossae, moist crepitation, having almost the character of mucous rales. Below this the respiration, both in front and behind, is quite feeble, and also over the whole of the 44 NOTE S OF CASES left side where it is mixed with a few sibilant rales. The expiratory breathing on both sides is quite loud ; while, on the contrary, the inspiration is weak. The first sound of the heart is replaced by a harsh souffle, [a blowing sound,] followed by a softer one, which, however, does not completely hide the second sound. These sounds have their maximum at the base, and are prolonged in the direction of the arch of the aorta. The pulse is small and irregular. The diagnosis of this case was somewhat difficult: but after reflection, I made up my mind that the only way of explaining both the physical and constitutional symptoms, as well as the progress of the disease, was by adopting the following definition: Tubercles in the second stage, occupying the whole of the apex of the right lung, with emphysema, and constriction of the aorta. Commenced treatment with the hypophosphite of potassa, in a dose of four grains; gave also ten drops of ethereal tincture of digitalis three times a day. June 19th.—Paroxysms of asthma have diminished in intensity and frequence; in every other respect is improving. Increased the dose to ten grains. August 21th.—Looks better in the face, but his lips are still purple; is well enough to attend to his business. On examination, I found the inspiratory murmur still very feeble, with prolonged increased expiration. The sounds of the heart still accompanied with a double souffle. The crepitation seems greater at the sum- mit of the right lung, and sound still more like a mucous rale. December 21th.—My patient has been absent to this date. The physical signs are now about as they were in August, but the constitutional ones are less satisfac- tory. With the coming of cold weather, his cough has increased, his breathing become more embarrassed, the asthma resumed its intensity. Commenced again with the hypophosphite of potassa, which was continued up to my departure in March, 1856. At this date, the paroxysms of asthma were quite rare, his cough was slight, his strength and appetite good. The tubercular deposit at the apex of the right lung was slowly softening; while the symptoms of asphyxia, evidenced by the blue color of his lips, and the rapidity of his respirations, were more increased. The sounds of the heart were about as before. There is no oedema.* The only observation which I have to make upon this case, and one which I have made in several others, is, that the hypophosphite of potassa seems to have a special influence in increasing the expectoration, and hastening the softening of the tubercles. In this respect it resembles the salt of ammonia. The constitutional effects seem about the same as those of the hypophosphites of lime and soda. CASE NO. XII. Dofia E. R----: 19 years old; born in Santiago de Cuba; married. Visited mo first at Havana, on December 1st, 1855.—She then gave me the following statement: Her father The infiltration of serum into the tissue of the lung, carried to such an extent as to diminish its permeability to air. Dropsical swelling produced by the accumulation of serous flnid in the interstices of the areolar texture. WITHOUT DECIDED RESULT. 45 and mother both died of consumption: she has no brothers or sisters ; has always been feeble and delicate. Two years ago, as her friends were alarmed about her health, she went to Europe, and passed a year with benefit. She married about twelve months ago, and a few months after, began to feel the first signs of her disease. This began with a slight cough, to which were soon added the other Bymptoms. For four months she has taken cod liver oil without any benefit, and for the past two months has vomited each time she has taken it. Her catamenia have been suppressed for five months. Her attitude shows great prostration; the emaciation is extreme; is very pale, and can scarcely walk; her voice is almost lost, but more from extreme debility than from disease; she has each day a severe chill, followed by cold, which lasts often for two hours, and is succeeded by heat; cough frequent, which fatigues her very much, and prevents her sleeping; there is scarcely a half hour in the day or night without a paroxysm; the expectoration profuse, muco-purulent, and mixed with mummular* sputa, which would fill three wine glasses in the course of the day. She is constipated, has no appetite, and sweats profusely at night about the chest and neck. I found, by an examination of the chest, on percussion, great resonance, which seemed about equal over both sides, but most perceptible in front. Auscultation showed cavernous rales occupying the whole of the left lung, both in front and behind. In one part of it free respiratory murmur could be heard. The same rales occupied about equally, in front and back, about a third of the upper part of that side. It was only in the inferior third that the respiratory murmur could be heard, and then very exaggerated and rude. The voice was so feeble that I could dis- cover nothing peculiar from it. The cough, in some places, sounds cavernous. Diagnosis.—Tubercles in the second stage, and several cavities occupying the whole of the left lung and the apex of the right. December 10th.—Began treatment with five grains of the hypophosphite of lime. December 14th.—Has a slight diarrhoea. Ordered eight grains of the lime salt, and ten grains of bismuth. December 19th.—Diarrhoea has stopped; has a httle fever each evening. In- creased the dose to fifteen grains. December 26th.—Has gradually improved. Have been gradually increasing the dose, so that now she is taking thirty grains of the hypophosphite of lime twice each day, morning and night. December 21 ih.—Was troubled in breathing; vomited twice in the night. Sus- pended treatment. December 29th.—The difficulty in breathing has disappeared. Ordered twenty grains of the hypophosphite to be given. March 8ih, 1856.—My patient has taken, with slight intervals, twenty grains of the hypophosphite each day. She has been steadily improving. Her husband being obliged, by his business, to return to Santiago de Cuba, has decided to taki her back with him. Her condition at departure was as follows: general appearance much improved. • An epithet applied to sputa, in phthisis, when they flatten nt the bottom of the vessel, like a piece of money. 16 NOTES OF CASES is stronger: has a better appetite; digests her food well; has no fever nor night sweats; the cough and expectoration are slight. Auscultation and percussion showed over the whole of the left lung great weak- ness of respiration, with slight friction sound, and marked resonance of the voice, but no rales. Under the right clavicle, in both scapular-fossas, there was dry crepitation, mixed with sonorous rhonchus, which disappeared for a moment, after a cough. There was also vocal resonance. This case has impressed me more than any I have treated. In presence of such lesions, I could not hope for a cure; but on seeing the improvement continue for more than three months, the constitutional and local signs disappear, I had every reason to regret the interruption to the treatment. She died about six weeks after her departure from Havana. But as to the subsequent symptoms I know nothing. I heard that she was found dead in her bed. CASE NO. XIII. Pauline L----: 15 years old; carpet worker. July 26th, 1857.-—This patient was sent to me by Dr. Lemaire, who at the same time addressed to me the following note: " I send you the young woman about whom I spoke to you this morning. Unfortunately, since I have seen her, the disease has made fearful progress. The cavity, which was limited at the beginning of the winter to the apex of the right lung, has now extended below the nipple. There is dullness over the whole anterior part of the'right side, the cavernous respiratory mur- mur being very great. She is much emaciated; has slight fever at night only; coughs constantly, especially at night, and cannot sleep.1' On examination, I found all these symptoms, with the following additional ones: Great rudeness of respiration over the whole lung, both in front and behind; some sibilant rales over the back; excessive night sweats; the catamenia suspended for nine months; appetite bad; has had diarrhoea up to two months ago; extreme weakness; pulse 112. Ordered at once eight grains of the hypophosphite of lime. September 1st.—No night sweats; less cough and expectoration; good appe- tite. Increased the dose to ten grains a day. September 16th.—Increased the dose to fifteen grains. September 25th.—For the two past days has had hemoptysis. Increased the dose to twenty grains. October 8th.—Decreased to twelve grains. October 13th.—No headache nor fever; no night sweats; no cough, and but little expectoration; appetite and strength good; pulse 120. Decreased to eight grains. October 18th.—Took a very long walk yesterday. Changed to the hypophos- phite of ammonia, at the dose of eight grains. November 26lh.—Up to this time she has remained in about the same condition. In December I lost sight of her. At this time she was living under most unfavor- able circumstances, being obliged to watch with a younger sister who was burned. WITHOUT DECIDED RESULT. 47 If this young girl had lived in a different, above all, in a climate less liable to produce inflammations of the respiratory organs, I do not hesitate to say that I think the result might have been favorable. The treatment lasted four months, during which time she was seen once or twice by M. Lemaire, who will bear witness to the great improvement which took place. CASE NO. XIV. Madame G----: 31 yeara old; living in Paris. September 30th, 1856.—Commenced coughing four years ago; her mother died of consumption three months ago; has lost flesh, especially during the past six lionths; her appetite is bad; has been taking cod liver oil without benefit; has uad no diarrhoea, but has lost her strength; has no night sweats, but some fever in the morning; the menstrual discharge is excessive, so as to constitute some- times a hemorrhage; there is ante-version of the womb, but no leucorrhcea; is generally constipated; has a persistent, painful cough, with copious, slightly mu- cous expectoration; pulse 84. October 1st.—The patient was seen by M Charles Bernard, who, as well as my- Belf established the following facts: Diminution of resonance, on percussion, in the right supra-scapular-fossa ; feeble- ness of the respiratory murmur in both scapular-fossae ; moist crepitation over the same region; slight resonance of the voice; in front, under the right clavicle, slight dullness; feebleness of the respiratory murmur; moist crepitation. Diagnosis.—Tubercles at the summit of the right lung, especially behind, in pro- cess of softening. October 2d.—Commenced with eight grains of the hypophosphite of lime. October 1th.—Feels much better; all the symptoms—the expectoration, fever and cough—have much diminished; is stronger, and has a good appetite. In- creased the dose to twelve grains. October 13th.—Formerly, at the approach of her catamenia she suffered intensely below the clavicles. This time she did not know of their approach until their appearance. The treatment was followed until the end of November, and then was suspended up to January, 1857. When examined at this time, she was found in a much more satisfactory condition, as far as concerned the constitutional symptoms, than before the commencement of treatment. The local symptoms were about the same: or rather, I should say, very slightly relieved, for it seemed to me that there was less crepitation. At this time I left Paris, and saw no more of her. It is to be noticed, in this case, that the disease was of long standing, and that, as far as prognosis was concerned, it had been sufficiently slow to give hopes of a favorable issue; but on the other hand, the severity of the lesions precluded the belief of any very prompt modification under the influence of the treatment The fact held good in this case, as in all others, that the time required to produce a favorable change was inversely, in ratio, to the anterior duration of the disease. In this respect it much resembles case No. 16. 48 NOTES OF CASES CASE NO. XV. Henri Maitre: 35 years old; jeweler's clerk; married ; living at Paris. His brother died of consumption eighteen months ago; is the father of tho pa- tient mentioned as case No. 9. October 11th, 1856.—Began to cough four months ago; for the past eighteen months his appetite has diminished; he has coughed much and lost flesh; his strength is good, but he loses his breath easily when walking, or mounting the stairs; has no night sweats. Was examined j'esterday by M. Charles Bernard, who discovered the following additional points: For the past month he has given up drinking, and finds his ap- petite in consequence a little increased, but he still loses flesh; no diarrhoea; food agrees with him; has one evacuation each day; sleeps well enough, but is often awakened by his cough; profuse expectoration of mucous. Over the right front there is sensible dullness, on percussion, for an inch below the clavicle, with resonance of the voice, and rude respiration. Over the right back, a diminution of resonance, on percussion; moist crepitation in both scapular- fossae ; vocal resonance. In the left sub-scapular-fossa there was crepitation, but no resonance of the voice. Diagnosis.—Tubercles in the second stage at the apices of both lungs. Ordered ten grains of the hypophosphite of lime. October 18th.—Increased the dose to twelve grains. October 21th.—Cough and expectoration less; appetite and strength better; in creased to sixteen grains. October 29th.—Increased to twenty grains. The great degree of improvement which this patient had exhibited was contin- ued through the whole of the month of November. On the 28th of that month I made an examination, and found that on the left side there was no longer either crepitation or vocal resonance in the sub-scapular-fossa, but the respiration was a little obscure on the right side. There was dullness under the clavicle, and be- hind I found slight crepitation in the sub-scapular-fossa. The patient, through the whole of his treatment, which lasted six weeks, did not give up his employment At the close of November, I gave up attendance upon him. I do not know what became of him afterward. CASE NO . XVI. Denis Delmotte: 25 years old; lemonade seller; born at Vertun (Pas-de-Calais) • living at Paris; married. Entered at La Charite under M. Charles Bernard, June 13, 1856. June 2\st.—Good constitution; parents both living and healthy, as also brothers and sisters. Symptoms commenced a year ago by an obstinate bronchitis, but with no constitutional derangements. The actual disease began six weeks ago, first manifested by a great and sudden loss of strength, general ill feeling, and in- crease of the cough. About a month ago there was a slight hemoptysis. There is WITHOUT DECIDED RESULT. 49 now a general paleness of the body, tho skin, lips, and conjunctiva; great weak- ness, although he is able to sit up a little each day; tongue clean; small appe- tite ; digestion good; no diarrhoea; urine normal; nothing noticeable over the abdomen; respiration easy, except there is a little difficulty of breathing when he is up; chest is well formed, with no external sign3 of disease; cough frequent, increased mornings and evenings. Percussion shows dullness under tho right clavicle, and also in the right supra- Bcapular-fossa. Found by auscultation, under the right clavicle, a drier respiration than natural, and by strong inspiration, slight crepitation. In the supra-scapular-fossa, very rude respiration, and the sound of bubbles, very sharp, unequal, and loud, over the whole region. In front, resonance of the voice equal on each side, though perhaps a little more marked on the right. In tho right supra-scapular-fossa it was decidedly stronger, and there was also bronchophony. The diagnosis left no room for doubt as to the nature of the disease, which was agreed to by MM. Bernard, Depaul, and Blain Descormiers. Tubercles at the apex of tho right lung, in the second stage. Ordered the hypophosphite of lime to be given in the following manner: On the 22d of June, three grains; 23d, five grains ; 25th, eight grains; 29th, ten grains; 30th, twelve grains; July 1st, fourteen grains; July 2d, twenty grains; July 7th, twelve grains. On all the days not named tho dose was to be the same as on the preceding one. July 8th.—M. Bernard states the general condition to bo improved; appetite and strength good, and no night sweats. Tho resonance, on percussion, below the right clavicle, a little less than on the left side, but scarcely perceptible; respiration a little rude; in both scapular-fossa?, moist crepitation; slight resonance of the voice; some dullness in the supra-scap- ular-fossa, and pain on percussion. In tho lower two thirds of the lung the res- piration is normal, as also over the left front. In the supra-scapular-fossa, slight dry crepitation; over the rest of that lung, respiration normal. July 9th.—Gave fifteen grains of the hypophosphite. July 10th.—Increased the dose to twenty grains. July 11th.—Reduced to fifteen grains, and kept it at that dose. July 30th.—Increased to twenty grains. August 5th.—General condition the same; some crepitation on the right side, over the whole of the upper part of the lung. August 14lh.—Treatment has been suspended for two days. August 18th.—Ordered four grains of the hypophosphite of potassa. August 19th.—Gave sixteen grains of the same salt August 20th.—Reduced the dose to ten grains. August 23d—Changed the dose to ten grains hypophosphite of lime. August 31st.—Changed to ten grains of the hypophosphite of soda. September 4th.—Went out, and remained all day, without fatigue; cough con- stant; streagth and appetito good; auscultation shows a great deal of crepitation in the right scalpular-fossa. September 1th*—Found at the base of the right lung, and over the whole of the 4 50 NOTES OF CASES mammary region, a very distinct friction sound, not disappearing at a cough. Sus- pended treatment, and ordered blisters. September 13th.—Left the city to remain two weeks in the country. M. Bernard examined him, with the following results: Slight dullness under the right clavicle ; moist crepitation for an extent of about an inch in the same region; crepitation in both scapular-fossae of that side, and also a slight rubbing sound at the lower part of the back. December 15th.—The patient remained in the country two months. There is now extreme oedema of the face and lower extremities; has little cough and expectoration. He states that on his journey by railroad from Paris, tho weather being stormy, he caught cold. On arriving at his destination, he was seized with headache, chills, and pain in the loins, vomiting and constipation, and total inability to urinate. The physician who was summoned, ordered, among other remedies, purgatives. From that time he began to swell up. Passing over the other signs which I discovered, I will only state that his urine, clear and frothy, was almost solidified by heat; otherwise, he was tolerably well; coughed and raised little, and had a good appetite. The resonance and percussion on the left side are normal; on the right side there is diminution for about an inch below the clavicle; over the same point, both in front and behind, there were sibilant and sonorous rales, mixed with some friction sound; nothing abnormal at the base. Ordered opium and iron, and that he be kept warm. December 21th.—The quantity of albumen in the urine has much diminished As at this time I left Paris, I can not say what afterwards became of him. In this case, as in the twentieth, there are the following peculiarities worthy of notice: The constitutional and local symptoms, before the commencement of treatment, were severe and well defined. There was an improvement, and finally complete disappearance of the former, while the latter showed that a process for elimination was going on. The alleviation of the constitutional symptons was sustained, es- pecially of the strength and appetite, in spite of the local organic difficulty. It is evident to me that, at the time I last saw him, there was an attempt being made to throw off the morbid deposit The acute inflammation of the kidneys (nephritis), was evidently due to his exposure to the cold. It is also evident that, without this, the albuminuria would not have existed; but the question arises, whether the state of plethora existing at his exit from the hospital would not predispose him to an attack. I am tho more inclined to regard this to be the fact, from tho case of a weak, delicate woman to whom I gave, for two consecutive days, twenty grains of the hypophosphite of soda; and who, also, had an attack of acute albuminuria. It seems to me that in these two cases there is more than a mere coincidence. I am aware that I am exposing myself to more than a single objection as re- gards this case; but I opposed, with all my power, the journey of the patient into the country, offering to furnish him with the means which he needed in order to remain in Paris. Although I had no reason to suspect the albuminuria, or any other inflammation, my opposition was also based upon the unpropitiousness of the season of the year for traveling. To-day I hear that he has completely recov- ered. WITHOUT DECIDED RESULT. 51 The use of any new remedy, or one of great power, is always attended with Borne danger. This constantly happens from the employment of quinine, mercury, and many other medicines. In every case where I have employed my treatment, I have been guided by the symptoms of the patient; and wherever my own ex- perience has not told me the proper dose, or the action of the salt with a different base, I have first tried it upon myself Thus, in addition to my first experiments with the lime, I have also taken either this salt, or the soda, in doses of from twenty to forty grains in the twenty-four hours. I have also tried the hypophoB- phite of ammonia in doses as high as twenty grains, although I knew that its ac- tion was unfavorable to the hepatic trouble with which I am yet affected. The reason for my mentioning these facts, is, because they are the best justification for the course I have pursued; and because I think this method the only way in which any really valuable discovery in therapeutics can be established. CASE NO. XVII. Ambrosine L----: aged 3 years and 9 months. July 29th, 1856.—Nineteen months ago her brother died of a cough at the age of 4 years and 9 months. She has coughed for the past fifteen months; has little appetite; has lost flesh, and sweats at night, especially about the head and neck; she has no diarrhoea, but complains of abdominal pains. Sleeps badly at night, and will start up suddenly, mugh agitated. Resonance, on percussion, normal; respiratory murmur diminished over the whole of the right lung, especially at its apex; in the supra-scapular-fossa, there is some crepitation, especially during a cough •, the respiration of the left lung diminished, especially over the back and at the. apex; the abdomen is enlarged, hard, and tender on pressure; pulse, 136; respirations, 38. Ordered one grain of the hypophosphito of lime. August 2d.—Has coughed less; is in much better spirits. Increased the dose to two grains. September 3d—The treatment has been continued at the same dose. Her general condition is now much improved, and her appetite is good; she has no night sweats; coughs less, and is quite gay; her stomach is no longer hard, nor painful on pressure ; she has gained flesh, and her mother says is as strong as be- fore her sickness; pulse, 130. September 10th.—Her mother did not bring her to me after this date, so that I am ignorant whajt became of her. CASE NO. XVIII. M. G----: medical student. August 1th, 1856.—The memoranda of his case, which this patient gave me, 1 have lost. My own were as follows; 52 NOTES OF CASES Has coughed every winter for the past five or six years; this year it has contin- ued into the summer. A month ago he had a profuse hemoptysis. Found the resonance in front almost normal except a very slight diminution on the right side. The respiration on that side is also a little feeble, with crepitation, and a few sibilant rales below the clavicle. On the left side the respiration was feeble below the clavicle. Resonance, on percussion over the back, about normal; respiration on left side healthy ; on the right, moist crepitation in both scapular-fossae, with feebleness of the respiratory murmur over the rest of the lung. Diagnosis.—Softened tubercles at the apex of the right lung; tubercles in the first stage over the remainder of that lung; on the left side, tubercles at the apex, in the first stage. Ordered ten grains of the hypophosphite of lime. October 11th.—By the advice of MM. Trousseau and Grisolle, my patient left for the Eaux Bonnes a few days after my last note. He continued my treatment there for twenty-five days, and then gave it up, by the advice of M GuSneau de Mussy, on account of the appearance of a little blood in the sputa. He has experienced a notable change for the better; his appetite increased; has no fever, but coughs a great deaL Ordered eight grains of the salt. October 28th.—The dose has been increased and continued at twenty grains. At this time, his strength and appetite have returned to their normal condition; he has gained a great deal of flesh; there is still some dullness at the apex of the right lung, but seems to mo much less than before treatment. In front, I can hear neither rales nor crepitation below the clavicle. In the supra-scapular-fossa, there are a few sibilant rales, but only heard at the end of a deep inspiration. Over the rest of the lung, the respiratory murmur is heard almost as well as over the left lung, where it seems to be normal. He has scarce any cough or expectoration. Treatment was now suspended for three weeks. At the beginning of January, he told me that his cough had increased while he had lost strength and appetite. On the 8th I recommenced the treatment at a dose of twenty grains, and by the 20th I found that his condition was even better than at the close of November. He was in this condition when I left Paris. CASE NO. XIX. Eugene Leroy: 17 years of age; printer; living at Paris; entered La Charite under M. Bernard. July 13th, 1856.—His disease commenced six months ago by a cold, but with- out fever or chill Since then his cough has not ceased. About a month ago, for two days, he spit blood, which was repeated two weeks later. From the com- mencement he has been troubled with night sweats; gave up work about a month after his illness began; has some appetite; has taken cod liver oil, but gave it up yesterday, because it produced vomiting; has fever and chills, especially when he tries to raise; pulse 112 ; respiration 36. His mother is alive; father died of a cold which he neglected; has no brothers and sisters. WITHOUT DECIDED RESULT. 53 There ia excessive debility and emaciation; expectoration of seven or eight characteristic mummular sputa, almost purulent; has not been up for fifteen days. Over the right front of the chest, there is dullness from the clavicle to the fifth rib ; intense cavernous respiration; pleuritic and friction sound, and great resonance of the voice; over the left front, rude respiration, difficult expiration, and some crepitation. Over the right back, diminution of resonance, on percussion, in both scapular- fossa ; cavernous respiration and rattling in the sub-scapular-fossa; considerable vocal resonance; over the left back, slightly diminished resonance, on percussion, in the supra-scapular-fossa, where there is rude respiration, and moist crepitation; at the base of that lung the respiration is still more rude. Diagnosis.—Large cavity at the apex of the right lung; tubercles in the left lung, in the first and second stages. July 11th.—M. Bernard has found the same signs, but in addition, moist crepita- tion over the rest of the right lung from behind. Ordered the hypophosphite of lime in a dose of ten grains. July 2lst.—Increased to twelve grains. July 23d—Increased to fifteen grains. August 6th.—At the base of the right lung, behind, the rales have disappeared, and been replaced by a very rude respiratory murmur; in front, there is strong cavernous respiration; on the left side, the respiration is feeble behind and ex- aggerated in front August 19th.—Has seemed to improve; his strength and appetite are better, but is much troubled by his night sweats, which are excessive; cough and expec- toration moderate in amount. Changed to the hypophosphite of potassa at the dose of seventeen grains. August 20th.—Auscultation shows same state; but at the base of the left lung, in front, the respiration is feeble; at the apex, both in front and back, there is great rudeness. August 28lh.—Sputa are highly colored with blood. Treatment has been sus- pended for two days. August 31st.—Changed to hypophosphite of soda at a dose of five grains. September 6ih.—Has had two watery evacuations, with colic all night, which prevented his sleeping; no appetite; cough and expectoration much diminished; pulse 108. Ordered fifteen grains of the soda. September 1th.—Reduced to ten grains. September 14th.—Has had no night sweats, but complains of having had chills all day and night; the cavernous respiration is less marked on the right side, and is replaced by a rude respiration and moist crepitation; behind, a mucous rale can bo heard over the whole extent; on the left side, in front, the respiration is rude; behind, there are some sibilant rales, and moist crepitation. Ordered sixteen grains of the hypophosphite of soda. September 18th.—Sweating a little less; expectoration a httle increased, with some blood. Increased the dose to twenty grains. September 21st.—Feels well enough to go out September 22d—Complains that he cannot sleep upon the left side; no more 54 NOTES OF CASES blood in sputa,; no chills; sweats very little; has a good appetite, but the cough and expectoration are much increased. Reduced the dose to live grains. September 14th.—Auscultation shows numerous rales over the whole of the right back; some crepitation at the base, and at the left back. Suspended treat- ment. September 30th.—Been troubled with diarrhoea; has had three liquid stools to-day; no sweating last night; less cough. Commenced again with eight grains of the hypophosphite of lime. October 5th.—Has had some diarrhoea up to this date ; pain on his right side, increased by coughing; raises some bloody sputa. Discontinued treatment I did not see this patient again. He died, I believe, in December. CASE NO. XX. Louis Duprez: 21 years old; type-founder ; born at Lille; living at Paris; un- married; entered La Charite, under M. Charles Bernard; is a foundling. August 23d, 1856.—Has suffered for the past three years with abdominal pains, but has never had lead colic; has been wretchedly poor for some time, and often suffered from hunger; says that his disease commenced six weeks ago, by cough and abundant expectoration of a transparent fluid; has had headache and difficulty in sleeping upon the right side. Three weeks ago, as a sequel to one of these headaches, and bleeding at the nose, he spit some blood. August 29th.—Has little appetite; no diarrhoea; tongue is white; has great thirst; no hemorrhage ; the abdomen is enlarged and tympanitic; no blue line on the gums; pulse 70. There is dullness under the right clavicle; in the same spot the inspiration i3 very rude, and the expiration rude and prolonged; there is also marked resonance of the voice; behind, there is the same dullness in the external part of the supra- scapular-fossa, as also the same changes of the respiration and voice, with the addition of moist crepitation; in front, on the left side, the resonance is normal • the respiration, above, is a little increased; behind, on the same side, after a cough, can be heard dry crepitation in both scapular-fossae, and the voice in the same locality is strongly resonant. Diagnosis.—Tubercles at the apices of both lungs, commencing to soften on the right side. August 30th.—Commenced treatment with the hypophosphite of soda at a dose of five grains. September 1st.—Increased to six grains. September 5th.—Increased to ten grains. September 6th.—Increased to fifteen grains. September 8th.—My patient tells me that two hemorrhoids have appeared, which trouble him very much; he says he never had any before. I examined and found two of the size of a small nut. Decreased to five grains. September 9th.—Increased to ten grains. September 14th.—Increased to sixteen grains. WITHOUT DECIDED RESULT. 55 September lbth.—Increased to twenty grains. September 18lh.—Was seized suddenly in the night with a violent hemorrhage, Which has now nearly stopped. Suspended treatment. September 21st.—The moist crepitation in the supra-scapular-fossa cannot now be heard. Commenced again with four grains of the hypophosphite. October 2d.—No diarrhoea; less cough; expectoration small; sweats very httle, and only on the back; appetite is good. Changed the dose to eight grains of the hypophosphite of lime. October 3d.—Under the right clavicle there is dullness, cavernous respiration, crepitation, and pectoriloquy; on the left side, rude respiration, and some vocal resonance ; over the right back, moist crepitation in the supra-scapular-fossa, and resonance of the voice; in the sub-scapular-fossa, rudeness of the respiratory mur- mur, and some crepitation at its inner angle; on the left side, the supra-scapular- fossa there is rude respiration, and moist crepitation more marked than upon the right side; in the sub-scapular-fossa, nearly the same symptoms, but the amount of crepitation is less; the respiration is increased over the whole chest October 5th.—Treatment ceased from this date. It is evident that there was an attempt going on in this patient to eliminate the morbid deposit formed before the commencement of treatment. The persistence of the diarrhoea depended probably upon some lesion of the intestine, which would create a doubt as to the probability of a favorable result Nevertheless, at the close of treatment, the patient was stronger and in a much better general condition than before, notwithstanding the symptoms had made such progress. Under this head, the present case should be compared with No. 16. Tho patient remained at the hospital until February, when he returned to his own part of the country. As I was not in Paris at that time, I can not speak with certainty as to his condition, or what became of him subsequently. Since that period, on further reflection upon this case, it has seemed to me that tho hypophosphite had not been given in sufficiently large doses, and that the lime was preferable to the soda. The dark color of the blood vomited up, the manner in which it made its appearance, four days after the disappearance of the hemor- rhoids, and its spontaneous cessation, also seems to me of sufficient importance to be mentioned. 56 NOTES OF CASES THIKD SERIES. CASES WHICH RESULTED FATALLY. CASE NO. XXI. Dona Josefa P----: 19 years old; married; born in Havana. Her disease com- menced two months ago, soon after child-birth. March 10th, 1855.—The patient is in a state of extreme prostration; her breath- ing is quick ; face anxious; has a hectic flush in the cheeks; pulse i3 rapid and thready; skin burning; stomach very much distended, and painful on pressure; cough and expectoration considerable; no appetite. Auscultation shows numerous rales, but of various degrees, over the whole of both lungs, both behind and before; the normal respiratory murmur can be heard nowhere; night sweats profuse; with diarrhoea. Diagnosis.—Acute tuberculosis of the lungs and intestines. March 13th.—Ordered one grain of the hypophosphite of lime. March 14th.—Four evacuations; increased to four grains. March 15th.—Diarrhoea less; increased to six grains. March 16th.—Says she has slept better; perspired and raised less; has had two evacuations; wants to eat, and dress, and get up; breathing seems to be easier, and the face has lost, in a great degree, its peaked and restless appearance. March 18th.—Much improved; sat up more than four hours yesterday; says she coughs less; had two stools, exhibiting some consistency. March 19th.—Increased to eight graiae. March 21st.—Was sent for in the afternoon, and on arrival found my patient in a complete state of prostration, covered with sweat; her features pinched, and with a continual hiccough; pulse almost imperceptible; stomach enormously distended, tympanitic, and excessively tender to the touch. She complained very much of a sharp pain in the right iliac and hypochondriae-fossae. Died in the course of the night. No autopsy. CASE NO. XXII. Dona A. G----: 31 years old; married; born in Havana; has been sick ei°-ht months. November 3d, 1855.—Face is pale and dejected; emaciation is extreme• cou"-h continual, and very fatiguing to her; expectoration purulent, and so copious that she fills a tumbler and a half each day; has great difficulty in breathing; no ap- petite ; there is fever, with chills at night; diarrhoea, and profuse night sweats. Physical examination discovered a marked augmentation of the resonance over WHICH RESULTED FATALLY. 57 the whole of the left side, especially over the back; rattling over the upper portion of the left lung, most noticeable behind; at the base, moist crepitation, most de- cided on the back, with great resonance of the voice; on the right side there was increased respiratory murmur. Diagnosis.—A cavity at the apex of the left lung, with tubercles in the second stage at the base. Ordered four grains of the hypophosphite of lime. November 5th.—Feels stronger; has less difficulty in breathing. Increased the dose to six grains. November 1th.—Increased to ten grains. November 10th.—Continued improvement; has been able to make quite long ex- cursions on foot and in a carriage. November 13th.—The weather has suddenly grown cold; to-day there is great dyspnoea, and the cough and expectoration have increased. Auscultation shows excessive rattling over the whole of the posterior portion of the left lung. Sus- pended treatment November 14th.—The patient was suddenly seized in the night with a violent pain in the left side; the respiration is quick; face anxious; auscultation shows strong cavernous respiration, occupying the whole left side of the chest, with great resonance on percussion. Diagnosis.—Pneumo-thorax. [An accumulation of air in the cavity of the pleura; a complaint generally sudden in its invasion, and fatal in its character.]—Teaks. Patient died on the 17 th. No autopsy. CA£E NO. XXIII. Mr. A----: 32 years old; born in England ; unmarried. Has been sick seven years; came to reside in Havana six years ago, by advice of various physicians in London, who informed him that the disease then existed in his lungs. After his arrival, his cough diminished, although it never wholly Btopped; he has lost flesh and strength continually since his landing; has never been treated here; but last year, finding himself weaker and more iU, he, by the advice of his physician, tried a change of air by returning again to his own coun- try. After his arrival in England, all the symptoms of his disease increased, and he was obliged hastily to take passage for Havana, which place he reached at the end of October. Since then he has been constantly growing worse ; has never had hemop- tysis. February 2d, 1856.—There is now excessive emaciation, with a deadly pallor; his debility is so great that he can scarcely take a few steps, even in his own room; constant and fatiguing cough ; expectoration purulent, and amounting in quantity to nearly a quart and a half each day; appetite very slight; alternate constipation and diarrhoea; constant fever, increasing at night; night sweats so excessive, that ho is forced to change his clothing several times during the night; great wakeful- ness; pulse, 110. On percussion, I found decided dullness below the right clavicle, for a space of an inch in breadth; below, however, tho sonorousness was increased beyond that on 58 NOTES OF CASES the left side. The same difference was perceptible in the corresponding positions behind. On auscultation, I found at the summit of the right lung, both at front and back, stong cavernous respiration, with great resonance of the voice; over the rest of the lung, lower down, starting from the upper edge of the second rib, cav- ernous rales, replacing completely the respiratory murmur; the vocal resonance varied according to the spot to which the ear was applied, but it was especially noticeable at the lower angle of the scapula; over the left side, both in front and behind, the respiration was increased; but there were no rales, crepitation, nor vocal resonance; sounds of the heart normal. Diagnosis.—A large cavity at the apex of the right lung; lower down, several multiple, but smaller cavities; one of them, however, at the base of the back, seems larger. Ordered ten grains of the hypophosphite of lime. February 4th.—Has sweat less, and slept better; the pain over the right side of the chest has nearly disappeared. Increased to fifteen grains. February 5th.—Increased to twenty grains. February 9th.—Continues to improve; has ridden out several hours each day; his appetite has returned; the expectoration is diminished one half, and has lost its purulent appearance ; no night sweats. Auscultation shows the same cavern- ous respiration, but the rales have nearly disappeared, and are replaced by a rub- bing sound, intermixed with sibilant rales. Changed to thirty grains of the hypo- phosphite of soda. February 10th.—In consequence of over-eating, he was seized with symptoms of indigestion, followed by colic and four or five free stools. Stopped treatment, and gave ten grains of bismuth every two hours, three times, and at night twenty drops of laudanum. t February 13th.—Ordered ten grains of the hypophosphite of lime February 14th.—Changed to twenty grains of the hypophosphite of soda. February 11th.—Changed to hypophosphite of lime, at a dose of thirty grains. February 20th.—Decreased to twenty grains. March 2d.—The weather has been so unfavorable for the past fortnight, that I was obliged to prevent his going out. To-day he requested me to discontinue my visits; because, as he said, he did not wish to continue the treatment longer, and be obliged to remain at home, regulate his diet, and above all, give up smoking. March 9th.—Was again summoned; had eight or ten liquid stools since morning, in consequence of having day before yesterday indulged too much in eating; the cough and expectoration have increased ; in consequence, he says, of having gone out in the cold. March 9th.—Evening.—The diarrhoea has slightly stopped, but he is still exces- sively weak. Commenced with ten grains of hypophosphite of lime. March 10th.—Died during the night: no autopsy. It would hardly have been reasonable to hope that this patient should recover, or tliat the organic lesions should be so modified that life could be continued in a quasi-normal manner; but at the same time, when it is noticed that the improve- ment was continued as long as the treatment was kept up : when this case is com- pared with No. 13, which was fully as serious as this, and moreover was not so favorably situated in regard to climate; and especially, if it is compared with No. WHICH RESULTED FATALLY. 59 12, where the disease was much more advanced, it seems to me not unreasonable to conclude, that with more docility on the part of the patient, his life would, at least, have been prolonged for some time. CASE NO. XXIV. Madam T----: 25 years old; living in Paris; sick for the past two years. July 4th, 1856.—Over the whole of both lungs, both at back and in front, mu- cous rales can be heard, which in some places have a cavernous character. This patient is nearly in extremis. Ordered ten grains of the hypophosphite of lime. This dose, continued for the three following days, produced no change in her condition. I therefore discontinued it. I should not have consented to the trial had it been possible to resist the demands and importunities of her family. She died a few days afterwards. CASE NO. XXV. Pierre Rostollin : 30 years of age; paper-maker; unmarried; born at Damencey, in Savoy; now living in Paris; entered La Charite June 21st, 1856.—Two years ago had bronchitis and pneumonia; otherwise has been well to last January; bis father died at 60 years of age, of some pulmonary trouble; a brother, 12 years old, died of a scrofulous abscess; has lived at Paris 12 years, and always regularly; in January, after a sudden exposure to cold, was seized with chills and a cough, which has been increasing ever since; has had con- stant diarrhoea, with progressive emaciation and weakness; says there has been no hemoptysis; since February the night sweats have been excessive, especially about the head and chest; his nails are curved, and hair falls out; the voice is a little hoarse, but otherwise natural. On the left side, in front, there is a little dullness towards the shoulder, with moist crepitation from the clavicle over the whole front of the left lung; the vocal resonance is somewhat increased. In various localities of the right lung, but especially below the clavicle, the re- spiration is very rude, and everywhere there is moist crepitation; under the clavicle there is small crepitation, almost approaching a crepitant rale; the resonance of the voice seems nearly equal on both sides. Over the left back, the sonorousness is diminished in the supra-scapular-fossa; and there, especially, is rude respiration, and moist crepitation, but less abundant than in front; below the spine of the scapula there is slight crepitation. Tho crepitation on the right side is most marked in the sub-scapular-fossa, but tho respiration is badly performed below this, and there is a distant murmur, which seems as if it might come from a cavity; the respiration in the lower two thirds of each lung is well enough performed. Diagnosis.—Tubercles, occupying the wholo anterior portions, and the apices at €0 NOTES OF CASES back of both lungs, in process of softening; on the left side there are evidonces ot a cavity; the diarrhoea probably depends upon the presence of ulcerations of tho intestines. June 23d—Pulse 105; respiration 36; skin hot; cough frequent; expectora- tion muco-purulent, of a yellowish-green color; constant thirst; httle appetite. Ordered five grains of the hypophosphite of lime. June 24th.—Increased to ten grains. June 21lh.—Diarrhoea all night; pulse 116. July 3d.—The diarrhoea, which has continued, has now much increased. Death ensued during the night of the 5th of July. The autopsy revealed a complete tuberculous infiltration of both lungs. In the left lung there was a cavity of the size of a large hen's egg; in the left, three or four much smaller. In the large intestine there were five or six ulcerations, occu- pying nearly the whole circumference for a space of some three or four inches in length. The other organs were not examined The only effect produced by the treatment was to render the night sweats less profuse. If, however, the lesions exhibited at the autopsy are remembered, it will be conceded that the treatment, no matter how efficacious it may be, could not, in such a case, produce any favorable change. CASE NO. XXVI. Alphonse Hure: 22 years old; unmarried; wine merchant's assistant; born at La Palisse (Mayenne); now living in Paris; entered La Charite June 13, 1856. July 5th.—Parents, brothers and sisters all well; disease began eight days be- fore entrance at hospital; after an exposure, he was seized with a cough, and raised more than a pint of blood; this was stopped by appropriate remedies for three days, when it recommenced and continued until eight days after his admission ; has profuse sweating; has lost strength; and since his admission has not been able to rise from his bed on account of the difficulty of breathing; appetite is poor; no diarrhoea; cough moderate; pulse 116; fever at night. On examination, found, over the right front, the sonorousness normal; the respi- ration rude; with well-marked vocal resonance; over the left front, the sonorousness normal with mucous and sibilant riles over the whole extent; with a resonance of the voice; over the right back, diminution of sonorousness in the supra-scapular-fossa, with total absence of respiration; rales and crepitation over the rest of the lung: over the left back, the sonorousness was normal; there were rales over the whole extent, having in some places the character of cavities, especially on a level with tho spine of the scapula, where there was also decided resonance of the voice, and in one spot pectoriloquy. Diagnosis— Acute phthisis, (it has made rapid progress since June 27th); tu- bercles in the second stage over the whole posterior portion of the right lung, with perhaps a tuberculous mass at the apex ; tubercles in the second stage over the whole of the left lung, with perhaps a cavity on a level with the spine of the scapula. WHICH RESULTED FATALLY. 61 Treatment: four grains of the hypophosphite of lime. July 21st.—Respiration 50 ; pulse 140. His condition has not been tnodified in the slightest by the treatment, except by the stoppage of the night sweats. July 24th.—Died yesterday evening. On the post-mortem examination, numer- ous resisting false membranes were found covering both lungs, and uniting the two sides of the pleura. At the apex of the left wno tnere 'w'ere two cavities, one of them as large as a hen's egg. Both lungs were completely infiltrated with caseous tubercles, except about an inch of the base of the right lung, and about two inches of tho lower posterior portion of the left. These two portions, by their cherry red color, contrasted singularly with the rest of the organ. These were found to be completely hepatized. The maximum dose was twenty grains ; increased from four grains, at the rate of two grains each day, and continued for eighteen days. CASE NO. XXVII. Justine D----: 16 years old; unmarried; lace maker; born at Ivry-la-Bataille ; living at Paris for the past seven years. Neither parents, brothers, or sisters, have been troubled with pulmonary affec- tions. Had catamenia when 13 years old; is sometimes troubled with leucorrhcea; has experienced pain between the shoulders for a year; began about two months ago to cough; before this was perfectly well, although delicate; has never raised blood; has had fever about four o'clock each afternoon since being sick, which continues until bed-time ; has also been troubled with night sweats; has no diar- rhoea, but has been sometimes a httle free; no colic; digestion is poor, and gene- rally vomits her dinner after an attack of coughing; has lost strength, appetite, and flesh very much; her temperament is lymphatic; constitution feeble; face pale and thin. July 9lh, 1856.—Over the left front, for about an inch below the clavicle, there IS decided dullness ; the sonorousness is sensibly diminished over the rest of the lung; moist rales and vocal resonance at the apex: over the right front the son- orousness is natural, but the respiration is very feeble : ove'r the left back, the sonorousness is sensibly diminished in both scapular-fossae; in the supra-scapular- fossa the respiration and cavernous rales are characteristic, and there is marked pectoriloquy : over the right back, respiration and sonorousness about normaL Diagnosis.—Acute phthisis; tubercles in the third stage at the apex of the left lung, and in the second stage in the remainder of that lung. Ordered ten grains of the hypophosphite of lime. July 13th.—Feels much better; the vomiting and sweating have wholly disap- peared, while the appetite and strength have returned; the cough has diminished. Increased the dose to twenty grains. July 31sl.—Auscultation shows an intense cavernous murmur in the upper two thirds of the left lung, both in front and back, but no rales ; at the base, feeble- ness of the respiratory murmur in front, and a few rales behind; the respiration is much exaggerated over tho right lung. From this day the treatment was stopped, and on the 7 th of September she 62 NOTES OF CASES died. This patient, from the moment she felt the improvement, persisted in taking long walks,, (sometimes for two hours at a time); she also committed other impru dences which hastened the fatal result. CASE N<5. XXVIII. A woman, (name unknown): domestic; 21 years old; under the charge of M. Briquet; says her parents, brothers, and sisters are well; was very strong up to the commencement of her present sickness; has had catamenia since 15 years of age; disease began about three months ago by a spitting of blood, which contin- ued for eight days; since then she has coughed constantly; says she has lost flesh; has had diarrhoea for eight days; can not sleep upon the left side; sweats much at night; expectoration is slight; skin cool; pulse 104. Chest well formed, with a slight projection over the right false ribs; abdomen normal in appearance ; over the left back, there is moist crepitation, through the whole extent of the lung, but its greatest degree is at the base ; it is increased by inspiration; in the lower two-thirds of that side there is marked resonance of the voice ; over the right back, at the apex of the lung, there is some slight crepita- tion. Diagnosis.—Miliary tubercles in the whole posterior portion of the left lung, with considerable hyperaemia [congestion] ; the right lung nearly normal, but with perhaps a few tubercles at the apex ; acute tuberculosis, in process of softening. Ordered ten grains of the hypophosphite of lime. October 11th.—The eruption of varicella has appeared; the diarrhoea continues. Decreased to eight grains. October 25th.—The pustules are drying up; she sweats very little, and has some appetite. November 25th.—There was perforation of the lung during the night, when death ensued. Although the condition of this patient was such that I could not hope for a dif- ferent termination, it is probable that if the variolous eruption had not appeared, there would have been a more decided improvement Even admitting that tho eruption had no direct influence in the softening of the tubercles, it is fair to sup- pose that it had upon the diarrhoea; and this certainly hastened the fatal result. CASE NO. XXIX. M. Eugene P----: 26 years old; unmarried; born in the department of Ar- dennes ; living in Paris for the past twenty years. August 19th, 1856.—Has been sick since the middle of May, at which time he wag attacked with fever and chills, spitting of blood, and pain in the lower posterior portion of the right side. Had a cough before that for the past three or four years. His family is healthy, and was himself very strong and healthy; but now WHICH RESULTED FATALLY. 63 he has lost flesh and strength; there is no appetite; a frequent cough; profuse perspiration, but no diarrhoea; nails curved; expectoration muco-purulent and profuse. In front, I found a slight increase of sonorousness in the right sub-clavicular re- gion, over the left lung; respiration over the left front almost normal; on the right, under the clavicle, there is a rude murmur, and moist crepitation ; behind, the son- orousness is normal; in the right supra-scapular region there is crepitation, with considerable vocal resonance; in the axillary space, sibilant rales, extending to the base of the lung. Diagnosis.—Tubercles on the right side, in the second and third stages, with bronchitis. Ordered four grains of hypophosphite of lime, to be increased gradu- ally to ten grains. September 3d.—Patient has gained much flesh and strength; his appetite is as good as before sickness; the night sweats have ceased; the cough and expecto- ration have diminished. September 5lh.—Changed to ten grains of the hypophosphite of soda. The phys- ical signs remain about as they were previous to treatment. The patient continued the treatment until the beginning of October; but he con- stantly committed imprudent acts, was wet one day in the rain, and several times exposed himself to draughts. After each exposure, or act of imprudence, there was a change in his condition for the worse. Ho died about the middle of the month. This case, as well as cases 31 and 33, dated the commencement of the disease to a syphilitic attack. I could find no secondary signs, but it is certain that each of these three cases experienced less alleviation from the treatment than all the others. ' CASE NO. XXX. Marie Hurel: 25 years old; singer; born at Versailles; family all healthy; has had two children, who both died at two and three years of age, respectively, of inflam- mation of the lungs, without convulsions. Disease commenced a year ago, with cough, loss of flesh, weakness, pallor, and menorrhagia. For the past four months there has been an aggravation of the symptoms, with hemoptysis, which once con- tinued a whole day. June 21st, 1856.—M. Empis, who examined her, drew up for me the following notes: Great pallor, weakness and emaciation; tongue clean; no appetite; digestion good; has had no diarrhoea; abdomen slightly tympanitic, and tender on pressure; the liver extends for an inch and a half below the false ribs. The catamenia had disappeared at the two previous epochs, but returned slightly at the last; pulse 104; increase of fever at night, followed by copious sweats; respiration short and quick; cough frequent; expectoration abundant, and com- posed of characteristic muco-purulent matter. Percussion shows dullness under the right clavicle, also especially marked in the supra-scapular-fossa of the same side. Auscultation shows moist crepitation under the right clavicle; in the right 64 NOTES OP CASES sub-scapular-fossa, a cavernous souffle, with bronchophonial resonance of tho voice; in the sub-scapular-fossa of the same side, some friction sound, which does not disappear during a cough, and is heard better during expiration than during inspiration. Diagnosis.—As given by M. Empis: Tubercles at the apex of the right lung, in the second and third stages, with a cavity. The condition of the left lung wa3 not mentioned by him, for the reason, proba- bly, that the notes of it were forgotten. The treatment was commenced with five grains of the hypophosphite of lime. June 23d—Increased to fourteen grains. July 2d.—Increased to twenty grains. July 4th.—Increased to forty grains. July 5th.—Decreased to twenty grains. July 1th.—Decreased to fourteen grains. July 8th.—Her condition has much improved; her strength and appetite have increased; the night sweats have ceased ; she gets up, and can walk down stairs, and about the garden. M. Bernard examined her to-day, with the following results: No pain on percussion; no dullness under the right clavicle, but the respiration shows a slight rudeness, with sonorous rhonchus; over the left front, the respira- tion is a little increased; over the right back, the sonorousness is diminished in both scapular-fossae; in the supra-scapular-fossa the respiration is feeble, and there is also slight moist crepitation, which is more marked in the sub-scapular-fossa; over the rest of that lung there are some few mucous and sibilant rales; over the left back the respiration seems almost normal. July 10th.—Had a chill last evening, which lasted for three hours, and was fol- lowed by fever and sweating. Ordered twenty grains of the hypophosphite. July 21st.—The patient has continued at the dose of the last date up to this time, with marked improvement; to-day she complains of a severe pain over the heart, which renders her breathing very difficult. Stopped tho iron, reduced by hydrogen, which she had been taking at the dose of one grain. July 26th.—No appetite; some diarrhoea. July 30th.—Diarrhoea stopped; pulse too frequent to be counted; cough has in- creased to such an extent that she can not sleep. August 1st.—Expectoration very profuse, and almost entirely purulent; respira- tion 40; pulse 136. Ordered thirty grains of the salt. August 3d.—Pulse 92 ; respiration 22. Ordered sixty grains of the hypophos- phite of lime. August 4th.—Pulse 126; respiration 30. Decreased the dose to thirty grains. August 5th.—Respiration 36; pulse very frequent; skin feels well; no diarrhoea; strength has increased; says her appetite is better; general appearance much im- proved. Increased to forty grains. August 1th.—Pulse 120; respiration 36. Auscultation shows mucous and sibi- lant rales occupying the back of both sides of the chest, especially at the base of the right lung; in front, a cavernous murmur over the whole lung; on the left side the respiration is sufficiently clear, with the exception of slight, dry crepitation at the base. Increased to sixty grains of the lime. WHICH RESULTED FATALLY. 65 August 9lh.—Symptoms of asphyxia; nail3 and lips are blue; considerable dyspnoea. Suspended treatment. August 13Ui.—Continued in about the same condition until last night, when she died. At the post-mortem examination, we discovered numerous adhesions between the two sides; a large quantity of serum in the pericardium ; a small cavity occu- pying the apex, and another almost the whole upper lobe of the right lung, with complete tubercular infiltration of tho rest of the lung, which was also much hepatized. The tubercles did not seem to be softening. The left lung contained a largo number of tubercles at the apex, with others scattered through about a quar- ter of its substance. These did not seem to be softened, nor suppurating, either at their center or periphery. The tissue of the lung was much hepatized; a small piece, placed in a glass of water, sank at once to the bottom. The liver was en- larged, and had undergone a fatty degeneration. The body contained a large quantity of blood, and presented none of those ap- pearances of anaemia which are generally found in the bodies of those who have died of consumption. The immediate cause of death in this case seems to me to have been an inflam- mation of those portions of the lungs which were not yet tubercularized. Tho question arises, was not this encouraged by the large doses of the medicine wliich were used ? In case No. 12, doses nearly equal were employed with advantage. It seems to me that in this case, as in two others which I have treated, the use of iron, simultaneously with the hypophosphites, has induced, almost immediately, symptoms of congestion or of inflammation. It is probable that under any treat- ment the disease would have resulted fatally; but with tho experience I have had, I think that this patient, if she had been in a warmer climate, or in one les3 sub- ject to atmospheric variations, would have experienced such decided benefit from tho use of this specific remedy as to havo prolonged life for a much longer period. CASE NO. XXXI. Charles K----: 33 years old; unmarried; waiter; born in the Grand Duchy o. Baden ; parents wero never affected with pulmonary complaints. August lih, 1856.—Disease commenced eight months ago with cough, but no pain or fever; has lost much flesh; strength and appetite have diminished; has been troubled with night sweats for the past four weeks, which were most profuse over the head, neck, and chest; about fifteen days ago his expectoration became bloody, but this continued for one day only; for the past six weeks has had one liquid evacuation each day: cough frequent and fatiguing; pulse 100. In front, the resonance is about normal on both sides; respiration more feeble at tho apex of the left lung than at tho right; cough and voice present no marked characteristics: over the back, the respiration is much more feeble on the left side, especially in tho supra-scapular-fossa, where there is also some moist crepitation; over the right back the respiration is about normal 5 66 NOTES OF CASES Diagnosis.—Tubercles in the first and second stages, at the apex of the left lung, with probably some intestinal disease. Treatment: Four grains of the hypophosphite of lime. August 9th.—The patient says the cough and expectoration have both diminished; is appetite and strength improved; and that the night sweats have almost ceased. ncreased to ten grains. September 1st.—Has been steadily improving up to this time. About ten days ago he began to complain of pains in the epigastric region, especially after eating, with desire to vomit; severe chills, followed by fever, recurring regularly; has had one or two attacks of bilious vomiting; one liquid evacuation each day; no dysp- noea. September 3d.—An eruption of psoriasis* has appeared over the back, which has a most suspicious copper color. Says that eight months ago he had a chancre, with running; the first was treated with a pommade, and was cured in eight days; the running lasted three months, and was cured with injections. It was at this time the cough commenced, which has continued ever since. September 8th.—Had four liquid evacuations yesterday, with considerable colic. Changed to ten grains of hypophosphite of soda. September 13th.—No night sweats, or chills; no diarrhoea; cough and expec- toration diminished ; appetite and strength good. September 30th.—Gave eight grains of the hypophosphite of lime; cough has increased considerably; has been troubled with vomiting, induced by the violence of it. October 4th.—Pulse 120; coughs and raises a great deal; one liquid evacuation; no vomiting; complains of sleeplessness; no headache, or pain over the chest; no night sweats, fever or chills; strength has much diminished. Changed to two grains of the hypophosphite of ammonia. October 6th.—Complains of pains in the epigastric region; no colic; two evacu- ations this morning. Increased to four grains of the ammonia salt. October 1th.—Increased to eight grains of the same. October 13th.—Changed to twelve grains of the hypophosphite of lime. October 15th.—Had an attack of bilious vomiting yesterday; no diarrhoea; coughs and raises less; sleeps better; has no fever, chills or night sweats; strength and appetite better. He continued in this condition up to the beginning of November; the diar- rhoea during this time steadily increasing. There were no noticeable changes in the lungs. His death was due to an aggravation of the intestinal symptoms. Taking into consideration the probable condition of the intestines, there can be no doubt that death must have sooner or later ensued; but I think this result was much hastened by his irregularities of diet. In this case, as also in cases 29 and 33, the improvement was not as well marked as in the others. All three dated the proximate cause of their disease to an attack of syphilis. * A cutaneous affection, consisting of patches of rdhgh, amorphous scales ; continuous, or of indeterminate outline. Dr. Willan gives names to eleven varieties of psoriasis, some forms of which are known as the Baker's Itch, Grocer's Itch, <&o.—Note by Trans. WHICH RESULTED FATALLY. 67 CASE NO. XXXII. Mademoiselle Amelie D----: Bister of the patient mentioned as case 34; has been sick Bince July, 1855. Her disease commenced with a cough, accompanied with fever, from excessive occupation. The fever lasted eight days, when it diminished, in consequence, she thinks, of taking cod liver oil. The improvement continued until March last, when the cough returned with greater severity than before ; she also, at the same time, began to lose her strength and appetite. In May she was attacked with a diarrhoea, which has persisted up to the present time, although controlled in some degree by narcotics and astringents. August 9th, 1856.—Was examined on the 30th of June by M. Louis, who made the following notes: Resonance about equal on the two sides; respiratory mur- mur most developed under the right clavicle, accompanied on each side with a su- perficial sub-crepitant rale; the same rale exists over the back, at the apices of both lungs; it is strongest on the right side, where there is also bronchophony; tho lesions'have about the same degree of severity on each side. In addition, I discovered in the right supra-scapular-fossa, a cavernous respira- tory murmur, with slight vocal resonance; on the left side, both back and front, the same signs as on the right side. She is now very weak, thin and pale; has still a diarrhoea; has night sweats; a chill and fever each afternoon about four o'clock; her cough is frequent, and pre- vents sleeping; catamenia did not appear at the last two periods; appetite almost gone. Diagnosis.—A cavity at the apex of each lung. Ordered ten grains of the hypophosphite of lime. August 26th.—Has had no diarrhoea for three days, but complains of chills, and a pain on the right side, at the base of the lung. Ordered a blister, loco dolenli, to be afterwards treated with powder of digitalis. September 5th.—Pulse 100 ; no fever or night sweats; strength and appetite in- creased ; no cough during day time, and but little at night; no evacuation for two days; came to visit me on foot. Changed treatment to ten grains of the hypo- phosphite of soda September \0th.—Since tho 8th has had fever and chills after her dinner, followed by profuse sweating; has coughed a great deal at night. Changed treatment to ten grains hypophosphite of lime. September 13th.—Complains of pain over the whole body; has had fever, with chills and sweating; some colic, but no diarrhoea. Changed to ten grains of the salt of soda. September 16th.—Pulse 102 ; at three o'clock yesterday she had violent chills, followed by fever and sweating through the whole night; no diarrhoea; has head- ache ; coughs and raises a httle; considerable thirst, and little appetite. Increased the dose of the salt of soda to fifteen grains. September 18ih.—Increased the dose to twenty grains. September 19th.—Pulse 100; bad fever all day yesterday, with chills and sweat- 68 NOTES OF CASES ing; has coughed and raised a great deal; no pain in side, but some headache; no diarrhoea; appetite better. Stopped treatment September 23d.—Less of the fever and chills; headacho still continues; has coughed and raised as much as usual; since last evening, no pain in side on cough- ing, but the oppression in breathing remains; no diarrhoea; pulse 104. Gave twenty grains hypophosphite of lime. October 2d.—The bad weather, and aggravation of her symptoms, have prevented her visiting me since the 24th; she has had, all the time, fever at night, and the night sweats worse than ever; pulse 100 ; headache still continues; yesterday had diarrhoea; strength and appetite have much diminished. Decreased the dose to eight grains of the hypophosphite of lime. October 4th.—Complains of vague pains; headache; profuse night sweats; but has no chills, fever, or diarrhoea. Increased the dose to twelve grains of the lime Bait. October 8th.—No diarrhoea or colic; no chills or fever ; sweating has diminished; cough and expectoration about the same; no appetite; pulse 108 ; strength in- creased ; has pain in the throat Ordered sixteen grains of the hypophosphite of lime. October 10th.—Diarrhoea; colic; chills; no appetite ; but the sweating has dimin- ished ; great pain in the throat, with loss of voice ; pain in the head; cough and expectoration increased. October 14th.—Diarrhoea has been stopped, and sleep obtained, by the use of laudanum; cough and expectoration unchanged; has sweat much; appetite and strength good; throat better; had much fever yesterday, from three to six o'clock. October 11th.—Headache much worso to-day, especially in front; no fever or diarrhoea; appetite better; sweats and coughs much less, and the expectoration ia also diminished; pulse 116; says she feels very much better; and her face has much improved during the past few days. October 20th.—The headache is still very severe, with pain in her limbs; had fever and chills last night; coughs and raises less; no diarrhoea, or pain in side; pulse 108. Gave twenty grains of the hypophosphite of lime. October 21st.—Has again ha"d diarrhoea. October 21th.—Diarrhoea has been checked; pain in throat, and cough, have in- creased; no fever or sweating. Decreased to twelve grains. October 29th.—Intense pain in throat. Gave twenty grains of the salt of lime. November 3d—Had bleeding of the nose yesterday; headache; no sweating or fever ; less pain in throat. Decreased to eight grains. November 6th.—Evacuation natural; great desire to sleep; less cough' and ex- pectoration ; appetite and strength better; the nose bled again yesterday; pain in throat still remains. Ordered twenty grains of the hypophosphite of soda November 11th.—Still coughs a great deal. Stopped treatment. November 12th.—No fever or sweating; great difficulty in breathing. Gave twelve grains of the salt of soda. November 11th.—Severe pain in the throat; otherwise entirely free from pain. November 27tfL—The weather has been so bad that she has not visited me for ten days—during which treatment was suspended. Ordered twenty grains of the salt of sbda. No notes were taken after this date, and a short time afterwards she died. WITHOUT DECIDED RESULT. 69 CASE NO. XXXIII. Sylvain Gabriel A----: 34 years old; carpenter; married; born in the depart- ment de la Creuse. His parents, brothers and sisters are all healthy. July 1th, 1856.—The patient can give but a very unsatisfactory account of his antecedents. According to his statement, he was attacked, in January last, with fever, which recurred every evening, accompanied with chills. In June, after hav- ing been engaged in washing his room, he was seized with a violent pain in the side, with cough, which has continued up to this time; has also the fever every evening, beginning at seven o'clock and lasting until four in the morning. The fever is not preceded by chills, but the perspiration moderate after it Says he has never spit blood ; is of a nervous-sanguine temperament; very thin, and so exces- sively weak as to be scarcely able to walk; has pain in the right side, on a level with the lower angle of the scapula, which is not stationary; cough is sharp and quick, and most troublesome at night; expectoration is mucous, and not very abundant; appetite small; digestion poor; is often troubled with colic pains. Resonance, on percussion, normal on both sides in front, except that the liver seems to extend from the level of the fifth rib, to about four inches below the false ribs. The respiration and sound of the voice seem about normal over the front of each sido of the chest; sounds of the heart natural; resonance, on percussion, normal over the back ; respiration not clear on either side, especially in the infra- Bcapular-fossa, where there is also dry crepitation, especially well-marked during a cough, and marked resonance of the voice. In the left sub-scapular-fossa, at each full inspiration there is friction sound. Diagnosis.—Is rather uncertain. probably pleuritic adhesions on the left side; some 6oftened tubercles on the right, on a level with the sub-scapular-fossa. July 14th.—Commenced treatment with ten grains of the hypophosphite of lime. August 12lh.—Since the last note, the patient has very much improved; he is stronger, and has much less cough and expectoration. August 26th.—For several days this patient has had fever, and intense cephalal- gia, occurring most frequently in the evening, but sometimes in the middle of the day, and generally preceded by chills. During this time digestion has been imper- fect, although there has been no diarrhoea; the night sweats have been excessive; so that yesterday he was obliged to change his shirt twice; his strength has much diminished. August 29th.—Had less fever, headache, and pain yesterday; have suspended treatment for the past eight days. Made another physical examination, and found decided diminution of resonance on percussion, in the whole right sub-clavicular region; in the same spot, feeble respiration, with dry crepitation, and some sibilant rales. At the base of that lung the respiration almost imperceptible, and some deep- seated sibilant rales; considerable vocal resonance under the right clavicle; on the left side, the respiration rude in various localities. Over the right back, the resonance, on percussion, about the same as on the left side; numerous moist r£les in both scapular-fossae, with great resonance of the voice; under the scapular, the respiration feeble; over the left back, the respiration about normal, with no vocal resonance; pulse 120 ; respiration 30. 70 NOTES OP CASES September 4ih.—Pulse 140 ; respiration 24; had chills yesterday; but no fever or sweating; has headache each morning on getting up. The patient informs me that about three years ago he had a chancre which lasted eight days, and was cured by cauterization. He has nearly lost his hair, but this he says preceded the vene- real disease; his fever dates from eighteen months back ; hi3 headaches for more than twelve years; there is no trace of an eruption over his body, and he saya there has never been any; but he complains of an itching, most troublesome at night, which he dates from five years ago; that is, two years before the chancre. September 9th.—Had two chills yesterday, one of which was followed by fever and sweating; his strength does not increase. Commenced treatment by ordering ten grains of the hypophosphite of soda. September 13th.—Came to see me on foot; pulse 120; no chills ; has sweat and coughed a great deal; appetite is good; no headache or diarrhoea. Decreased the dose of soda to five grains. September 16th.—Fever ; sweating; intense gastralgia and headache; no appe- tite ; pains in the arms and shoulders at night; does not cough or raise much. Stopped the treatment. October 1st.—Is in about the same condition; is excessively weak, and troubled by his night sweats, having to change his shirt four or five times each night; has a burning fever for about four hours each morning, with violent headache ; palpita- tion of tho heart; pain in the right side, under the nipple ; cough dry, and much increased; no diarrhoea; pulse 12Q. Auscultation shows decided dullness over the whole of the right side, both at back and front; respiration almost gone in the whole of the right lung, except by a forced inspiration; in various places, especially behind, can be heard deep-seated dry crepitation; voice and cough more resonant than on the right side; on the left side the resonance, on percussion, seems about normal; the respiration is slightly increased, and in the sub-scapular-fossa there is some crepitation ; the voice and cough present no marked characteristics; the pulsations of the heart can be felt below and to the inner side of the left nipple, having its point in the epigastrium; its sounds are normal, but there is a slight souffle at the first moment Commenced the treatment with ten grains of the hypophosphite of ammonia. October 6th.—Increased the dose to twenty grains. October 1th.—The patient has passed a wretched night; the fever and sweating were excessive; prostration is so great that he has much difficulty in even sitting up. Decreased the dose to six grains. October 9th.—Has improved somewhat. Increased to ten grains. October 10th.—All the symptoms, general and local, have improved. October 11th.—Saw some streaks of blood, yesterday, in his expectoration; aus- cultation reveals the same signs as before, but more marked on the right side; at the base of the left lung, behind, there are some rales; the friction sound has diminished; under the left nipple, a slight sibilant rale. October lllh.—Says he has passed a better day than for some time before; has had no fever or sweating; appetite is good ; has no headache or palpitation; can walk about his room ; cough is tho same; and there is still blood in his sputa,. October 20th.—Fever and sweating the whole night; is much weaker; has no ap- petite ; headache and palpitations havo returned. Decreased tho dose to four grains. WHICH RESULTED FATALLY. 71 October 2lsi.—Changed the treatment to eight grains of the hypophosphite of lime. October 26th.—Feels better; has coughed and sweat less. Increased the dose to twelve grains. October 21 ill.—Decided improvement. Ordered sixteen grains of the hypophos- phite of lime. October 29th.—Reduced the dose to eight grains of the lime salt, with the addi- tion of twenty grains of the hypophosphite of potassa. November 6th.—For the past eight days he has been taking twenty grains of the hypophosphite of potassa. The expectoration has increased ; but tho fever, chills, and sweating, have much diminished; he has scarce any appetite or strength. Ordered ten grains each of the hypophosphite of soda, potassa, and lime. November 1th.—Has more strength and appetite ; coughs and sweats very little, but expectorates enormously. November 8th.—Passed a good night; was suddenly attacked this morning with a violent pain over the whole right side of the chest, with violent dyspnoea; cough frequent, with profuse purulent expectoration. The resonance, on percussion, is very great over that side, with amphoric respiration. Died six days afterwards of pneumo-thorax. No autopsy. There was probably a complication in this case of an old pleurisy with adhesions of the pericardium. For this reason the treatment was employed with hesitation, especially at the outset It seems to me, now, that the specific treatment was not decided enough at the commencement; that it was suspended too often, aud that the doses were not large enough. Tho use of the hypophosphite of potassa and ammonia in this case, as iu some others, appeared to increase the expectoration and other signs of tubercular soft- ening. Tho salt of ammonia likewise caused a discoloration or blackness of the stools. CASE NO. XXXIV. Mademoiselle Julie D----: sister of the patient given as case 32 ; 25 years old. Was examined on the 1st of July by M. Louis, who made the following notes and diagnosis: Dullness under the left clavicle for some distance, with feeble or bronchial re- spiratory murmur, accompanied by sub-crepitant rules; same condition over the back, on that side; but less marked; right side normal; the left lung only is tuber- culous, but is affected to a great extent. July 8th.—Saw her for the first time. She says she was ill four years ago from an attack of pleurisy, but that she recovered from this and continued in good health for a year and a half; two years ago, began to cough and lose flesh; cata- menia have never been regular; has had leucorrhoea; is much weaker than for- merly; never has spit blood ; sweats only at. night, when fatigued; has a shifting pain in the left shoulder, so that she cannot sleep upon that side, as it causes her to cough; coughs constantly, but most at night and morning; expectoration ia 72 NOTES OF CASES. muco-purulent; her voice has become much more feeble for tho past six months; bas no pain, on pressure, over the larynx, but some pain in the throat, particularly when in the act of swallowing. There is dullness over the upper two thirds of the left side, both before and be- hind ; respiration is feeble, and varied by dry crepitation and some sibilant rales; there is resonance, on percussion, on the right side, with normal respiration. Diagnosis.—Tubercles in the first and second stages, occupying the upper two thirds of the left lung. Ordered ten grains of the hypophosphite of lime. September 1st.—She has steadily improved up to this time, and has gained so much in strength that she has been able to attend to her business, as before her sickness; her appetite is good ; there is no fever, night sweat, nor diarrhoea; at the end of July her catamenia returned as regularly as ever, but they did not appear at this period, owing, as she thinks, to a fatiguing walk which she took, and a cold which she caught at the same time; since then she has had headache, with slight fever and some sweating. Ordered a mustard foot-bath at bed-time. September 2d.—Catamenia appeared slightly yesterday. September 3d.—Catamenia were suppressed yesterday. September 6th.—Cough and expectoration have been increased since the suppres- sion of the catamenia. Changed to ten grains of the hypophosphite of soda. September 10th.—Gave five grains of the hypophosphite of lime. September 15th.—Changed to ten grains of the soda salt. September 18th.—Gave twenty grains of the same. September 22d—Cough has slightly increased. Reduced the dose to ten grains. September 29th.—Catamenia appeared yesterday. October 4th.—Sweat more than usual last night; had fever and chills at night; cough is frequent; no appetite. Gave four grains of the hypophosphite of am- monia. October 11th.—Has had fever and chills every night, with headache ; cough and expectoration somewhat diminished. Increased the dose to twelve grains of the ammonia October 15th.—Pain at the left side, on level with the seventh rib, when she coughs. Her aunt tells me that she attributes the aggravation of her symptoms to family troubles and care. October 11th.—Gave twelve grains of the hypophosphite of lime. October 23d.—Has had all the time more or less fever with the chills; pain in her throat, which makes it difficult for her to swallow; cough and expectoration less. Increased the dose of lime to sixteen grains. October 29th.—Has had no fever since last date. Gave twenty grains of the hypophosphite of soda. November 28th.—Has continued in about the same condition; the difficulty in her throat gradually increasing; the fever, cough, and sweating were much less. The patient did not visit mo after this date, and died at some time in the earty part of January. REMARKS UPON THE CASES COMPOSING THE THIRD SERIES. Deducting the first six cases, in which the disease had almost reached a fatal ter- mination at the commencement of treatment, the following remarks will apply to all the rest of those composing the third series. In the last seven cases there was a well-marked and persistent alleviation, espe- cially noticeable in the complete change in tho attitude and physiognomy of the patients, in the disappearance or modification of the constitutional symptoms, and in the decided increase of the strength. Of these seven cases, it seems to me that in four, (viz., Nos. 27, 29, 32 and 34), after this amelioration (especially remarkable in cases 27, 29 and 34), there was a renewed aggravation (immediately following in case 27), in consequence of re- peated walks of several hours' duration; and in case 29, of having remained ex- posed to a draught of cold air at the gate of the Tuilleries, where he had run for Bhelter from a shower. Tho subject of case 34 had recommenced her ordinary labor, as before her illness, and was even detained later than usual on account of the approach of New Year's day. Grief and domestic cares appear to have at least contributed to the sup- pression of her catamenia, the return of which was the extent of the improvement which she at first experienced. Tho aggravation in case 32 was especially noticeable at the approach of bad weather. In this case, as also in cases 28 and 31, there existed for sometime be- fore treatment a diarrhoea which resisted all remedies. In caso 31, this complication was increased at several different times by excesses in diet. It is reasonable to suppose, that, with regard to case 28, tho variolous eruption, if it did not hasten the softening of the tubercular deposit, already far advanced, at least contributed, by its influence upon the intestines, to aggravate the already existing diarrhoea Finally, analyzing the details of these different cases, it seems to me their fatal issue ought to be directly attributed to the anatomical lesions existing before the treatment, and to the pathological consequences which these lesions would neces- sarily produce. Whatever may have been the influence of the treatment upon the diathesis itself, it could not act, except indirectly, upon the physical results already produced by the diathesis. For the same reasons that an anti-venereal treatment will not pre- vent a bubo from suppurating, whenever the local inflammation has attained a cer- tain severity; or the organic lesions of the viscera, resulting from malarious fevers, will not disappear directly under the influence of sulphate of quinine; so an anti- tubercular remedy, while removing the cause of the disease, cannot restore the local lesions which are the results of it. The maxim, sublata causa, tollitur effectus, in reality applies only to functional disorders; while organic lesions, once estab- lished, will follow the course which is peculiar to them, and which, to a certain ex- tent is independent.of that which has produced them. This will be still more evident if the cases of the third series are compared with those of the first, which resulted favorably. 74 ADDITIONS TO ADDITIONS TO THE PRECEDING REPORT. If the hypothesis, that all tubercular diseases arise from a diminu- tion of the oxydable phosphorus contained in the human system, shall be finally sanctioned by experience, it will naturally induce a modification, to a certain degree, of all the present ideas of the etiology, pathology, and even of the semeiology of these affections. It would be premature, at this time, to speculate upon these changes, until the fac's I have ad- vanced have been confirmed by a more extended series of experiments • but there is something to be gained, in my opinion, by examining cer- tain questions raised by the subject itself, and which it is necessary to solve before deciding what is the limit to the efficacy of the treatment I have proposed. How can it be expected, it is asked, that the hypophosphites of lime and soda should cicatrize a cavity, or cause the disparition of a bronchial dilatation ? To this I answer: we cannot always expect such a result; and dis- appointment will certainly follow if the treatment is looked upon as in- fallible. Indeed, clinical experience may, perhaps, demonstrate that this permanent relief occurs rarely. All that we can reasonably ask is, that the treatment should dissipate the diathesis—that peculiar state of the body which has, as a consequence, the deposit of tubercular matter. When once this condition has been modified, the deposition of fresh TUBERCULAR MATTER WILL CEASE. As to the morbid products existing anterior to treatment, two things will happen: if they are fresh, they will in some cases be absorbed ; if they are old, they must follow out the indications of their own inde- pendent existence, and result naturally, either in calcification, in becom- ing encysted, or in elimination by softening and suppuration. This is a repetition of the two deductions I have before mentioned, and.upon which I now again insist: firstly, that the treatment will act with just so much greater rapidity, according as it is resorted to at an early stage in the progress of the disease; a fact recognized under every form of treatment, and by all practitioners: secondly, that when the local le- sions have attained a certain degree, the prognosis depends entirely upon THE PRECEDING REPORT. 75 their gravity, their extent, the constitutional condition of the patient, and the position, as regards hygiene and climate, in which be happens to be. Under these circumstances, it is all-important for us to place the pa- tient in a hygienic and climatic position, which will, especially during the time occupied by the process of elimination of the tubercles, remove him as much as possible from the chances of those inflammatory com- plications to which he is so liable. The respiratory organs in all consumptives have an extraordinary sus- ceptibility to these troubles, which is easily explainable from the fact of their being already the seat of a pathological action, of which the prin- cipal feature is a hyperemia of all the tissues about the tubercular de- posit. Moreover, the patient is prostrated by his sickness, and conse- quently much less in a condition to resist meteoric influences. This specific treatment, by increasing materially the nervous power, places the patient under the most favorable conditions to meet the sud- den changes of temperature ; but on the other hand, as it also increases the quantity of the blood, it likewise augments the relative state of plethora, and renders him more liable to a development of inflamma- tion. In warm climates, where all inflammations of the respiratory organs are infinitely less severe, or frequent, than in Europe, the most simple precautions are sufficient, and the treatment can be employed at its maximum. In cold countries, especially during the winter, it is highly important not to go beyond the point of sanguification which, if I may so express myself, comports with the condition of the patient. Health consists, in reality, in a perfect equilibrium of all the func- tions : nevertheless, for a patient, a part of whose respiratory apparatus does not work, or in whom there is at the same time going on a process for the expulsion from the economy of some injurious element, there is a certain abnormal, or, as medical men call it, unstable equilibrium, which it is necessary to maintain. The art of recognizing, and treat- in^ in every patient, this unstable equilibrium, constitutes medical skill. I therefore particularly recommend to all practitioners tho necessity of watching that their patients do not abuse the state of improvement which this treatment superinduces, often in cases of the gravest charac- ter. It is difficult to persuade a patient who is no longer troubled with ni£ lb. Being predisposed, oaher mother's side, she had had cough for three months, with very slight expectoration ; no haemoptysis ; no night-sweats ; and had no other illness. Tho catamenia, absent since the commencement of her illness, were previ- ously regular. Digestive organs regular ; pulse 112. The physical signs were dulness and crepitation at the right apex cf the chest anteriorly, wit'i dulness,and loud, harsh expiration at the left apex posteriorly. Treatment__.Hypophosphite of soda, dissolved in gum mucilage, was given threo times a day, commencing with doses of ten grains, and gradually increasing to half a drachm by the 17th December. Result.—After twelve weeks' treatment ia tho hospital, there wxs evident improvement in lu-allh and strength; she had gained half a stone (sevenpounds) in weiglU, couglied less, and the crepitation at the right apex was heard only after coughing; no expectoration. Tho catamenia had not returned, and tho pulse was still above 100. The like treatment was subsequently continued, as an out-patient, until April; at which time she was slated to bo very ill, and sho diod soon afterwards, PHTHISIS IN THE FIRST STAGE ; IMPROVEMENT WHILST TAKING HYPOPUCSI'HITE OF LIME. Cask 2. R. C----, aged 21, a shipwright, admitted Nov. 23d, 1S58 ; height, 5 ft. 8 in. ; weight, 8 st. 10>£ lb. Being predisposed to consumption oa his mother's side, his illness com- menced with an attack of licemoptysis to tho amount of half a pint whilst he was at work. This continued for three or four days to a slight extent. He has been losing weight and strength ever since. lie stated that he had had no cough until ton days before admission, and his ex- pectoration, which was muco-purulent in character, was in very small quantity. He had had no hemoptysis since tho first attack, and suffered no pain in his chest. His appetite was net good, and his bowels were costive ; pulse 96. The physical signs were dulness and bronchial breathing at the right apex. Treatment.—For ten weeks he took the hypophosphite of lime, in doses of tea grains, gradu- ally increased to a drachm, three times a day, dissolved ia an infusion of gentian ; after which he had cod-liver oil alone, for two weeks,in place of the mixture. Result. — Under the hypophosphite he improved in health and strength, and gained eleven poumls and a half. His condition then became stationary. Whilst taking the oil, he did not increase further in weight, though ho felt equally well. His cough was trifling, with only slight expec- toration ia tho morning, but he still experienced some dyspnoeaon exertion. His appetite was very good, aud pulse 92. The physical signs were much tlie same as on admission, the dulness being,perhaps, less marked, and the respiration less bronchial in character. Dec. 1859.—This patient hasnottaken any medicine since he left the hospital. Ho has retained his improved condition, and now continues in much the same state as when he left. 114 APPENDIX. PHTHISIS IN THE SECOND STAGE J TEMPORARY IMPROVEMENT WHILST TAKING HYPOPHOSPHITE OF SODA. Case 3. II. B----, aged thirty-one, a laborer, was admitted on the 31st of January, 1859 ; height, 5 ft \% in ; weight, 7 st. 3>i lb. With no hereditary predisposition to consumption, ho had coughed for two or three winters, and had had hamoptysis to the amount of half apint three months previously to admission, and to a less amount nine months before that. His ex- pectoration was very purulent and in considerable quantity; his appetite was bad; and his pulse about 100. The physical signs were dulness and crepitation at Vie right apex, extending low down. Treatment.—For throe months ho took the hypophosphite of soda dissolved in infusion of gentian, commencing with doses often grains, three times a day, and gradually increased in five weeks to forty grains, three times a day. Result.—He improved during the whole lime he was in hospital, steadily gaining strength; his appetite was good, cough became much less, with scarcely any expectoration, except a littlo greenish mucus latterly ; his pulse was about 80 ; and in tho first two months and a half ho gained nine pounds and a half, and lost two pounds in the subsequent fortnight. The crepitation at the apex cf the lung disappeared allogetlier in front; it was still audible at tho apex poste- riorly ; the inspiration in front was weak, and the expiration harsh. Ho left the hospital with the means at his disposal of continuing the remedies. He gradually, however (after two months), began to decline, and when seen on Dec. 10th, 1859, ho pre- sented tho signs of cavities in the right lung, and of progressing disease in the left. PHTHISIS IN THE SECOND AND THIRD STAGES ; LITTLE OR NO IMPROVEMENT WHILST TAKING HYPOPHOSPHITE OF SODA. Cask 4. C. W----, aged thirty-two, a needlewoman, was admitted on Dec. 10th, 1858" height, 5 ft. 4 in. ; weight, 7 st. 8 lb. She had been out of health for five years, and was with- out hereditary predisposition to phthisis ; but had had slight cough for a year, which became much worse six weeks before admission. Her expectoration ivas very purulent, rather nummu- latod, and very copious, and it had been occasionally streaked with blood. She had dyspnoea and pains in tho chest. Tho catamenia were irregular, and had not appeared for six weeks. Her appetite was bad, and pulse above 100. The physical signs were dulness, bronchial breathing, and crepitation on the right, with greater dulness, cavernous respiration, and crepitation on tho left. Treatment.—She had the hypophosphite of soda in doses of ten grains, gradually increased to forty grains, three times a day, dissolved in infusion of gentian and gum mucilage, and continued for twelve weeks. Result.— Her cough became less troublesome, and the amount of sputum diminished considera- bly. Her appetite also improved, but she did not gain strength. Her pulse remained above 100- tho catamenia did not reappear, and she lost a pound and a half in weight. PHTHISIS IN THE FIRST AND SECOND STAGES ; NO IMPROVEMENT FROM HYPOPHOS- PHITE OF LIME; MARKED IMPROVEMENT SUBSEQUENTLY FROM COD-LIVER OIL. Case 5. W. J----, aged forty-three, a blacksmith, was admitted on the 23d Novem- ber, 1858 ; height, 5 ft. hyt in. ; weight, 9 st. 11 lb. He had no hereditary predisposition to phthisis, but had coughed for five months after taking cold. His expectoration was purulent, but he had never had hemoptysis. Ho had had no night sweats; his appetite was good; pulse, 92. The physical signs wore dulness, bronchial respiration, and crepitation at tho apex • with dulness, deficient inspiration, and loud expiration on the left. Treatment.—For six weeks he had the hypophosphite of lime, ten grains, which was then Increased to fifty, three times a day, dissolved in gum mucilage and infusion of gentian ; after which the treatment was changed to cod-liver oil, which he took for seven weeks. Result.— Under the hypophosphite ho did not progress satisfactorily—felt weaker, coughed more, and lost two pounds in weight; while the disease rather advanced in tbel'ungs.tho APPENDIX. 115 crepitation being still heard at the right apex, and some coarse crepitation also at the left. Soon after commencing tho oil he began to improve, gaining strength and weight—five pounds and a half in all; his appetite improved ; and he coughed and expectorated less. PHTHISIS IN THE SECOND STAGE ; NO IMPROVEMENT FROM HYPOPHOSPHITE OF SODA ; SUBSEQUENT IMPROVEMENT UNDER OTHER TREATMENT. Case C A. M. S----, aged twenty-seven, a ladies' maid, was admitted on Feb. 3d. 1859, height, 5 ft. 4 in. ; weight, 7 st. 7 lb. With predisposition on her mother's side, she had had cough for three years, brought on by sleeping ia a damp bed. Her expectoration was muco- purulent, but not in very great quantity. She never had hamioptysis, pains in tho chest, or much dyspnoea. Her appetite was variable. She had lost very much in weight; and the catamenia had been absent for four months ; pulse about 100. The jmysical signs were dulness and extensive coarse crepitation on the right side. The left apex presented similar signs of disease, but with less dulness and less crepitation before and behind. Treatment.—She had the hypophosphite of soda for three weeks in doses of ten grains. It was then increased to forty, three times a day, dissolved in gum mucilage. Result.— Under this treatment there was no sensible improvement. She did not gain strength, and she lost half a pound in weight. Her appetite was bad, and latterly she com- plained of epigastric pain, unrelieved by suspending the use of the remedy. The treatment was changed to a mixturo of infusion of gentian, carbonato of soda, and diluted hydrocyanic acid, aud continued for three weeks. She also took some purifloti cocoa-nut oil. Under this plan she certainly improved, especially during the last fortnight. Her cough was dry, but sometimes troublesome. No crepitation could be heard on the left, and only a little at tho right apex, nor appetite was much better, and she gained strength and two pounds in weight. The catamenia also returned. PHTHISIS IN THE FIRST AND THIRD STAGE ; NO IMPROVEMENT FROM HYPOPHOS- PHITE OF SODA. Case 7. C. F----, aged twenty, a shopwoman, was admitted on Nov. 31, 1S58 ; height, 6 ft. 1 in. ; weight, 6 st. 10 lb. Without family predisposition to consumption, sho had coughed for more than a year, with purulent expectoration, and had had haemoptysis on three or four occasions ; the catamenia were irregular; sho had lost a good deal cf flesh, and her appetite was bad. The physical signs were dulness, with cavernous respiration and crepitation on the right Bide, with loud, prolonged expiration on the left. Treatment.—For the space of three weeks she took the hypophosphite of soda, ia doses of ten grains, three times a day, in mucilage or infusion of gentian ; for five wetlcs before this, and for three months and a half after, she had ordinary tonic treatment, with a little cod-liver oil. Result.—She gained a little strength througlvout, and the catamenia appeared regularly; but there was not much alteration in tho cough. Whilst taking the hypophosphite, she lost three pounds in weight ; whereas, during the whole of the rest of the time, she maintained her weight without loss. Conclusions.—r.eviewing the cases, of which the preceding may be said to be types, we see that of tweuty-two individuals laboring under phthisis, submitted to the hypophosphite treatment, sixteen derived no benefit whatever ; ia three the benefit was so slight and tem- porary as scarcely to deserve notice ; in two the improvement, though marked, was tempo- rary ; and hi one case the result has been satisfactory and permanent. Small as the thera- peutical powers of the hypophosphites are shown to be by these facts, are we justified in assigning to them even thus much? 1 think not. For we cannot forget that our cases are hospital cases ; that, oppressed by sickness, care,and anxiety,they come from close, unhealthy localities ; that they were more or less destitute of good food and good air. When they eater the hospital, they begin to feel the influence of hope ; they live in warm, airy, and well-venti- lated wards, find agreeable occupations, and have plenty of good food. Under such circum- 116 APPENDIX. stances, tho patients frequently improvo inhcalth, without tho application cf any modicinal agents. It would thercforo bo as fair to attributo tho slight temporary improvement which took place in some of these cases to hygienic as to thorapoutical agencies. A review of tho preceding facts has led mo to form a most unfavorable opinion of tho value of hypophosphites in the treatment of phthisis, I believe them to be comparatively,}/ net absolutely, useless. I have been induced to take somo little pains in investigating the sub- ject, becauso of the unhesitating confidenco with which their value is asserted and their use recommended ia certain quarters, and 1 have also seen in the cases of some patients who havo visited Paris how much time has been thrown away by substituting the use of these salts for remedies of undoubted efficacy in controlling the progress of phthisis. ANALYSIS OF THE PPtECEDING KEPORT. It i3 a lamentable circumstance when the narrow spirit of bigotry intrudes itself upon tho councils of science ; but it is more lamentable when it mixes its pernicious shade with questions deeper than science, and which involve the well-being of the race. To the man of catholic views and philosophical culture, the spirit of medical bigotry is, of all others, the most incomprehensible, because it so manifestly outrages the very nature and conditions peculiar to medical science, and substitutes irrelevant and impertinent assumptions in the place of inductive experiment. The intelligent reader, who has carefully exam- ined the preceding report, cannot have failed of observing how this spirit, inspiring the whole, darkens in self-contradiction and unconscious perver- sions ; nor with what ungraceful reluctance it permits the confession of benefits of the most unmistakable and significant character. In my analysis of Dr. Quain's report, I do not think it necessary to make an exhaus- tive re-statement of Dr. Churchill's theory ; but it may be well to sketch, succinctly, certain distinctions not generally recognized by the profession, and which appear to have escaped the attention of Dr. Quain especially. Dr. Churchill adopted the use of the hypophosphites simply as the first of a series of inorganic remedies, with which he proposed experimenting; intending, subsequently, if these should fail, to use others. But observe, their failure would not have disproved the correctness of Churchill's general hypothesis. The essential and original feature of his theory being, simply, that it is to the inorganic constituents of the fluids that we must look for the special cause of jthe tubercular diathesis, and of all diatheses, he " concluded to begin his experi- ments, towards determining this question, with phosphorus." (p. 12.) He had not yet '' concluded that the failure was in phosphorus as a constituent of the body." Hypothesis, of course, preceded experiment, but experiment confirmed hypothesis ; and it was not till then that he asserted the therapeutical superiority of phosphorus, in the particular form of the hypophosphite, over the usual treatment. That phthisis is proximately caused by some aberration in the processes of sanguification and nutrition, is an old doctrine, by no pieans original, nor claimed to be original, with Dr. Churchill. Its recogni- APPENDIX. 117 tion is universal. To deny it, is to charge empiricism upon the very treatment pursued in the Brompton Hospital! The problem, therefore, was : whether is the special cause of the tu- bercular diathesis to be found in the excess or waste of some inorganic, or in the excess or waste of some organic, constituent of the blood ? Already, as he states, (p. 12), and as all intelligent practitioners know, Mil. Andral, Gavarret, and others, had demonstrated that the variations in the composition of the blood, so far as its organic constituents arc concerned, have no peculiar relation to pulmonary phthisis. Dr. Quain characterizes these propositions as "theoretical speculations;" but the reader will observe that experiment had already taken them out of the misty region of "speculation," and had established them upon the solid ground of demonstration, before Dr. Quain interposed this objection ; and he will also^ce, I trust, that, however unsupported by chemical observation in their inception, they were yet, even then, not without negative confirmation from the physiological observations of the authorities just cited. Dr. Quain is not very clear in his statement, but he 6eems to say that phosphorus was exhibited in a low state of oxydation, chiefly because, in this condition, it is " more capable of assimilation." Assimilation is certainly important, but it is the oxydation of the phosphorus in the economy which is the essential fact, because its '' oxydation constitutes one of the essential phenomena of sanguification" (p. 91). In looking critically over the particulars of the cases reported by Dr. Quain, the conviction is irresist- ible, that his "conclusions" arc not only unsupported by his facts, but that they arc in direct and obvious conflict with them. I doubt if any capable reader could reflectively examine this report— divested of the interested special pleading of its author—without concluding that the hypophosphites exhibited, in these cases, most remarkable and ener- getic tlierapeutical powers, notwithstanding their undoubted impurity. But let me indulge in a few general strictures, before I animadvert upon the particular characteristics of the report which I have yet to consider. Of the cases reported, and which are said to have been taken, ".without selec- tion, from amongst the ordinary in-patients of the hospital," the first was admitted on the 3d November, 1858 ; the second, fourteen days after—on the 17th ; two were admitted twenty days after—on the 23d ; one, thirty-seven davs after—on the 10th December; one, eighty-nine days after—on the 31st January, 1859 ; and one, ninety-two days after—on the 3d February. The general statements of the report, even the very words, " without selec- tion," convey the impression that the twenty-two cases were treated simul- taneously. But if the fifteen unreported cases were taken in the same manner as the reported cases, after long intervals, it would be interesting to know when Dr. Quain's "experiments" began and when they ended! Treatment was commenced in tlie seventh case—admitted November 3d, 1858—on the 8th December, and was continued three weeks. The result was most unfavorable. Thus, by the 31st December it was known to Dr. Quain, according to his own showing, that the hypophosphites were " absolutely useless." Of course, US APPENDIX. then, he straightway abandoned their use ? Oh, no ! Ho still continued his remorseless "experiments" upon the unsuspecting twenty-two, during periods of from onetj sixjnonths, and thus wasted precious time '' in the uso of these salts," when he was in possession of "remedies of undoubted eftcacy m controlling the progress of phthisis!" But if it is said that the patients were not put under treatment by the hypo- phosphites directly upon their admission to the hospital, the question arises : What treatment was employed during the long period between the first and the last cases ? And were they not rather manifestly taken, at last, because of their hopeless condition ? I think this last question must be answered affirmatively. Any otheran- swer is inadmissible, not only because it is impossible fairly to deduce any other answer from the report, but because any other answer would make us blush for Dr. Quain's humanity. It is better to be classed with the unfair and disingenuous, than with the reckless or heartless experimentalists But th13 conjecture is. negatively sustained by the consideration that not one of the cases, in which the hypophosphites are said to have failed, subsequently recovered by the use of the "remedies of undoubted efficacy." It cannot bo doubted, I think, that if the cod-liver or cocoa-nut oils, or the "tonics " had cured a case in wlitch the hypophosphites had failed, so conclusive a fact would have been circumstantially set forth in the report. But no such fact is found I now pass to a consideration of the doses. One hundred and eighty grains of hypophosphtte are said to have been administered to each of four patients daily for several consecutive weeks ; enough to have endangered or des- troyed the he of the patient, ,/ the salts had been pure, in half that period Thisis a simple question of chemistry, and every chemist knows that oxy- dtzabUphosphorous cannot be safely used in these very large doses ujbrr*0'but one possibi°deduction fr°m thesc facts: the -»« UoonU ^ m S°me °f thGSe CaSGS' ™stW ^^ excessively rmpure. Upon th s vitally important point, however, the report vouchsafes no ifght Irt t fr T? mdeCd' n0t *° haVC C°nsidered ifc of the sli^tcst import- ed °thaThara, \f ^ eXpe"ments' or t0 W own character as an'ob- notw-tW «^T^1" TOY °f th°sMs ^-me satisfactory tost notw.thstanding that their manufacture requires great delicacy Z SST "* ^ "" *** olt strong temptatZ £ of observing w +17 ,, 7 f hlblted thpm » his practice, can have failed - tzzzfz *°trr tindicated by Dr-ci—• AorMvA -J- ? !• !' "improved powers of innervation;" the decided stimulation of the functions of nutrition ;" the increased vjrf the appetite; hecessation of the night sweats of phthisis; the " unusu 1 fLl ngof comfort and strength;" and, after a time-according to the ^ yn" ^c^r,W <,Pleth0rV' ^ Ph— " *« - I can only wonder at the reckless audacity of the man who ventures upon APPENDIX. 119 their denial. But Dr. Quain ventures even beyond this. He has, assuming the purity of the salts he employed, declared that the hypophosphites, as such, arc "absolutely useless," and that they possess no more therapeutical power than "so many grains of carbonate of soda or prepared chalk." (!) Upon the truth of this extravagant proposition depends the whole value of Dr. Quain's report. Let the profession, then, submit its truth to a personal test—to such a test as it was not submitted by Dr. Quain. I have no fear, no doubt, of the result. I know, rather, that it will convict Dr. Quain of wanton ignorance and insincerity. There are many things in this report which I cannot critically notice, without danger of prolixity, and of fatiguing the patience of the reader ; but there is a particular paragraph which, in connection with what has just been said, so clearly discovers the spirit of its author, that I cannot forbear an allu- sion to it. The original treatise, from which Dr. Quain pretends to quote the passage: "I know that they will prove not only as sure a remedy in con- sumption, &c," contabis no such language. The reader will find the passage in the Appendix to the translation (p. 99), which was compiled by the Ameri- can publisher, and which was not embraced in the French edition. At page 100, there will be found, in the same letter, Dr. Churchill's strictures upon the report of Dr. Quoin's colleague—Dr. Cotton—a circumstance which is carefully ignored by Dr. Quain. Surely, then, the presumption is not strained nor unfair, that the present report was written for the very purpose of vindicating the conclusions of the other, and of supplying its designated deficiencies; and the presumption be- comes almost a certainty when the reports arc examined in the light of Dr. Churchill's letter : for an ingenious attempt is made to escape the particular objections urged by Dr. Churchill against the first report. Committed to a cause without merit, the advocate and the special pleader take the place of the man and the philosopher. Remarks o.v the Cases. — My first objection to the reports of the cases is, tliat they arc characterized by a diplomatic vagueness of statement, as if the language were used with reference to its capacity for concealing the truth. This vagueness is out of place in a scientific paper, such as this report is de- signed to be. When exact statements are possible, hypothetical statements arc an impertinence. My second objection is to the extreme meagreness, and the inconsist- encies even, of the record of the physical signs. If the reader will take the trouble to compare the careful and elaborate records of Dr. Churchill's cases with those of Dr. Quain, the "meagreness" will be clearly illustrated; the " inconsistencies" I will show by citations, in the proper place. My third objection is, that in only one of the cases—the sixth—(and this incidentally) is there any account made of the complications. Case I. The physical signs, in this case, are stated with an approach to particularity, but the result reported, as to these signs, is not very clear. It is said that "the crepitation at the right apex was heard only after coughing;" but nothing is said as to the " dulness and liarsh expiration at the left apex poste- 120 APPENDIX. riorly." This is an example of the "inconsistencies" I have charged upon the report. Is it imfair to infer, then, that these signs had disappeared ? If they had not, why did not Dr. Quain make his case stronger by saying so ? The improvements in strength, weight, and " liealth," together with the dis- appearance of several of the unfavorable symptoms, do not sustain Dr. Quain's extraordinary conclusion, that "there was nothing more felt by the patient than if so many grains of carbonate of soda, &c, had been given." But it is said that the termination was finally fatal. "The reader will notice, however, that Dr. Quain does not say whether or not the patient died of phthisis. He probably did not know, since he only affirms that it "otj stated" to him that the patient was " very ill." Of what ? Could anything be more vague ? Case H. This case is, in many respects, the most remarkable of the series ; but it is chiefly remarkable as an illustration of Dr. Quain's manner of giving the hypophosphites "a fair trial," and of the "vagueness" with which I have charged him. Nothing could be more satisfactory, certainly, than the final result in this case ; "for ten weeks [the patient] took the hypophosphite of lime," and gained eleven and a Iialf pounds in weight, while his strength and '' health'' are acknow- ledged to have "improved." But this appears to have alarmed Dr. Quain, and accordingly we find him substituting '' cod-liver oil for two weeks !'' But alas! the patient's "condition became stationary" under the oil—doubtless much to Dr. Quain's chagrin ; for if he had continued to improve, the oil might have been credited with the happy result. Then follow characteristic examples of vagueness : '' the physical signs were much the same, the dulness perhaps was less marked, and the respiration [perliaps?] was less bronchial." Now, all this is unworthy—to use no harsher word—even of Dr. Quain; the "physical signs" ivere, or were not, the Kame; the "dulness" was, or was not, "less marked;" the "respiration" was, or was not, "less bronchial." Why use such obscure phrases as " much the same" and " perhaps," where exactness of statement is not only possible, but natural and necessary ? If Dr. Quain had exhibited thirty grains of a pure hypophosphite once a day, in the place of sixty grains three times a day, of the hypophosphite which he did exhibit, he might, perhaps, have furnished us with a more decisive record. Case III. This case is marked by comparatively unimportant discrepan- cies between the record of the physical signs and the results, but still it is marked. The conceded improvements in the general condition "during the whole time," the remarkable accumulation of flesh and the entire disappearance of the "crepitation at the apex of the lung in front," are results which can- not be pettifogged away—not even in favor of the balmy airs and the unctu- ous diet of the hospital! Amongst the physical signs enumerated, no mention is made of any diffi- culty in the left lung ; but in December, 1859—when the patient "began to decline"—Dr. Quain mentions, for the first time, a "progressing disease in the left lung!" It is said, also—and I request the reader's particular attention to this point-that the patient left the hospital " with the means at his disposal of APPENDIX. 121 continuing the remedies." As the man was " a laborer," it must be supposed that the '' means at his disposal'' were furnished by the hospital; and thus we have Dr. Quain in the singular act of permitting the hospital's means to be used in the purchase of remedies "absolutely useless," instead of fur- nishing the patient with the "remedies of undoubted efficacy in controll- ing the progress cf phthisis!" But Dr. Quain did, or did not, know whether the patient '' continued the remedies.'' If he did know, he should have said so, and thus have added the force of a positive statement to his report; if he did not know, candor requires that he should have mentioned so material a circumstance. Again : If Dr. Quain was dissatisfied with the progress made by his patient under the hypophosphite, it is not a little mysterious that he did not insist upon a change of treatment while the patient was still under his personal care ; since this seems to have been a case in which the " tonics and cod-liver oil" ought to have vindicated their vaunted superiority. Case IV. A "little improvement" is confessed in this case, of which the reader can judge. It will be observed, however, that nothing is said about the final result, nor are we told whether the patient was subsequently treated with the " tonics and cod-liver oil;" nor, if so, with what benefit. Case V. We arc left in similar darkness about the ultimate issue of this case. Neither arc we told what interval occurred, if any, between the suspension of the hypophosphite and the administration of the oil. The oil gets cred- ited, though, with the subsequent improvement, notwithstanding tliat the exhibition of the hypophosphite might have been a material condition prece- dent to such improvement. The obscurity of the phrase, " did not progress satisfactorily,'' and the omission of any specific reference to some of the pre- viously-mentioned physical signs, justify the inference that, in spite cf the loss of weight and an apparent aggravation of some of the symptoms, a favorable change had been effected in the diathesis. Cask VI. This is the only case in which any reference is made to complica- tions. The patient "complained of epigastric pain "—is the brief chronicle of Dr. Quain upon this point. The objections urged against the fifth, may be repeated against this case, d fortiori. Case VII. In this case, also, the same "discreet silence," mentioned by Dr. Churchill, and pointed out in the preceding strictures, is observed as to the final issue of the disease. It is characterized by the same want cf clearness, by the same disingenu- ousness, by the same manifest pre-detcrmination of judgment, which so conspicuously appear throughout the whole report. We have the incompatible statements that, whilst taking the hypophos- phite (for three weeks only), the patient " lost three pounds," and yet that she '' gained a little strength throughout.'' Wc are told, likewise, that, '' during the whole of the rest of the time," her weight " was maintained ;" but we are left to conjecture whether " the rest of the time " includes the previous five weeks, or only the subsequent three months and a half. If the decline commenced—as is most probable—during the first period, it was scarcely 122 APPENDIX. reasonable to suppose that a three week:;' tre^hncniwith a hypophosphite of doubtful purity would fully arrest it ; and it i.j impossible to determine (as there was no interval, remedy immediately succeeding remedy) the extent to which the hypophosphite contributed to the subsequently '' maintained '' condition. We are now prepared to estimate the " conclusions" of Dr. Quain at their true value ; and it will be conceded, I think, that they are not only unauthor- ized, but that they arc contradicted, by his facts, and that, therefore, the report is absolutely valueless, so far as its opinions are concerned To the final eulogy upon the advantages of the Brompton Hospital—its airy and well-ventilated wards, its agreeable occupations, its plethoric dietary, and its copious rose-water, I have nothing to object. I have nothing to object to the truism, that when the sick have the best care they recover most rapidly ; nor that much credit is due, generally, to hygienic influences, as well as to therapeutical agencies ; but I do object to the very illogical application which Dr. Quain makes of all this. Let this be made clear. In a general statement qf his " conclusions," embodying, as I have cheerfully -admitted, much truth, Dr. Quain would seem to claim that the whole improvement in the cases was clue to the advantages of the hospital ; but he carefully avoids making the claim specific. It was easy, and indeed his duty, to say, if he thought it true, that the particular cases, 1, 2, and 3, for example, were benefited solely by these advantages. But such a statement would have been obviously untrue. Accordingly, the reader is left with a gene- ralization, true in itself, but false when applied to the facts before him, and 'with the apparent hope that it will be so applied. I cannot conclude these strictures without calling the reader's critical at- tention to the singular account which Dr. Quain gives, in his closing para- graph, of the motive that prompted him to enter upon his investigation of the claims of the hypophosphites: singular, in that he assigns, as his sole rea- son, " the unhesitating confidence with which their value is asserted, and their w.sc recommended, in certain quarters." It would bo interesting to know just what Dr. Quain means by " certain quarters." He cannot mean Dr. Churchill, for he has referred to him by name. He cannot mean to refer to the obscure old ladies who have such unlimited faith in sage tea, and who furnish those wonderful "testimonials" to the nostrum-mongers, for that would be be- neath the dignity of Dr. Quain. But if he means, as he plainly does, to refer to respectable members of his own profession, it would be of some advantage, without doubt, in making up an impartial judgment upon this controversy! to know upon what grounds they established their conclusions. Perhaps it might appear that they arc as competent to conduct such an Inquiry as Dr. Quain; perhaps it might appear that the investigations, which resulted in impressing upon them so favorable an opinion of the value of the hypo- phosphites, were conducted with at least as particular a regard to the various conditions cf success—with quite as unselfish and impartial a devotion to the interests cf science and humanity—as were the experiments which led Dr. Quain to do imfavorablo a conclusion. APPENDIX. 123 I cannot better bring this article to a close than by calling the attention cf tho reader to the abundant und authoritative evidences—to be found i:i another Appendix—of the success of the hypophosphites in the hands of the profession of this country ; or than by entreating him to remember the words cf their distinguished discoverer, addressed to his brethren on this side of the Atlantic—but more needed on the other side of the British Channel : "In therapeutics, as in every other department of experimental research, no number of negative instances can outweigh one positive result, obtained under cer- tain determinate conditions, unless it be at the same time shown that, in tho negative instances, all these conditions have been expressly complied with." (p. 103.) J. WINCHESTER. 43 John Street, i\T. T., June, I860. [From Braithwaite's Retrospect: iVo. XXXVII] FIRST REPORT OF THE BROMPTON HOSPITAL.* ON THE "SPECIFIC" ACTION OF CERTAIN SALTS OF PHOSPHORUS IN PHTHISIS. ET DR. RICHARD PAYNE COTTON. My experience of this remedy is based upon carcfully-mado observations upon twenty cf my own in-patients at the Hospital for Consumption. Copious notes were taken 1 y Dr. Walker and Mr. Ford, the resident clinical assistants, and arc open to the inspection of those who may be desirous of obtaining more information than I am able to offer in the present communication. Dr. Churchill's rule3 for administering it were carefully attended to ; five grains dissolved in water, with the addition cf a small quantity of syrup, being given three times a day. The cases consisted of nine males and eleven females, all of whom were adults. Three were in the first stage of consump- tion, five in the second, and twelve in the third. All were affected with the disease in its simple form, there being no other than the ordinary complica- tions. The remedy was administered for a fortnight, notes being regularly taken ; if at the expiration of this period no improvement was observable, it was discontinued; but if the patients expressed themselves relieved, other medicines were prescribed with the view of testing whether such relief was fairly attributable to " specific" agency, or to other circumstances-such as improved diet, rest, &c, which should always be taken into account in esti- mating the effect of medicinal agents upon hospital patients. Of °the three patients in the first stage of the disease, two were not per- ceptibly influenced by the hypophosphites, but afterwards improved consider- * See Dr. Churchill's letter, p. 100. ]24 APPENDIX. ably under tonic treatment and cod-liver oil; the other considered himself much stronger, but before admission to the hospital he had been almost starved, so that good diet, &c, may reasonably claim a fair share of the credit; and he left before other medicines could be tried. Of the five patients in the second stage of the disease, two were not in any way influenced by the hypophosphites, but subsequently expressed them- selves as feeling "much better" under tonic treatment, with cod-liver oil; two slightly improved, but one of these afterwards advanced at a much more rapid rate under steel and oil, and the other seemed to get on quite as well under steel and quinine ; the remaining one became much worse from a gradual advance of the malady. Of the twelve patients in the last stage of the disease, one felt herself bet- ter under the hypophosphite than under any other remedy ; one improved greatly, but not more than under the subsequent use of other tonics ; three improved slightly, but afterwards progressed much more rapidly under steel and cod-liver oil; two were not at all benefited, butfound themselves " much better" under a change of treatment; in two cases no effect was observed, and in spite of all treatment the disease ran on ; one of the patients became worse, but subsequently gained strength under the oil and quinine ; the re- maining two died. Thus, in only two instances could this remedy be said to act with any marked benefit, and in one of these its good effect was very equivocal, the patient previ >us to admission having been in an almost starving condition, and leaving the hospital before the comparative trial could be made with other medicines. In all the rest itactcd certainly in no way as a ' specific;" in most, it seemed to be inert; and the few cases which slightly improved during its administration were evidently instances of the post, and not the propter hoc, s:n?e some advanced equally, and many of them more rapidly, un- der the subsequent use cf steel or quinine with cod-liver oil. It is very possible that the compound of phosphorus proposed by Dr. Churchill may, in some cases, have a tonic and beneficial influence ; but to any " specific" action upon tuberculosis it seems to have no claim. The employment of phosphorus in the treatment of phthisis is by no means novel. For the last eight or nine years I have been in the habit of using a mixture consisting of the dilute phosphoric acid with the phosphate of ircn ; and at my suggestion it has been inserted in our hospital pharma- copoeia. In many cases much good has attended, and I think I may say been produced, by its administration; but I attribute it to no specific action. I believe it is a simple tonic, adapted to certain depressed states of the sys- tem. Phosphorus is a well-known and apparently necessary constituent of all healthy nerve structure ; and, in some conditions of low nervous vigor, its medicinal employment may be of great service. We find that it°en'tcrs largely into the ccmpcsiticn of the mest nutritive kinds of grain ; and Ave may be quite euro that it is not placed there without a purpose. APPENDIX. 125 [From the JV. I'. Medical Press, March 31, 186X] THE HYPOPHOSPHITES IN SOME CONDITIONS OF DISEASE IN YOUNG CHILDREN. BY O. C. GIBBS, M. D. Every physician who has been called upon to prescribe for young chil> dren, has frequently seen cerebral symptoms suddenly occur, thus complica- ting the case, and often disappointing his most sanguine hopes of a favor- able issue. Symptoms, not unlike those which characterize acute hydroceph- alus, occasionally supervene in the progress of other diseases, which, unless promptly and appropriately met, terminate a case fatally that might other- wise have recovered. It is of the first importance that this complication, which is pathologically antagonistical to meningitis, should be promptly dis- tinguished and correctly diagnosed from hydrocephalus. In the complication under consideration, the thoughtful and observing physician has doubtless felt the need of a more promptly efficient brain- stimulant and tonic. It is often the case that death could be averted if tho nervous energies could be aroused and temporarily sustained. A case, illustrative of the above remark, came under our observation a few months ago, and it may not be uninteresting to briefly allude to its more important features. November 15th, 1859, we were called to see a female child, aged eleven months. The child was of a decidedly scrofulous habit; had from the first few weeks of life been troubled with scrofulous sores and cutaneous erup- tions, but at present it was suffering from an attack of pneumonia. The general and physical symptoms were all well marked. We ordered syrup of ipecacuanha, spirits of nitre, and paregoric, in appropriate doses, for internal remedies, and applied mustard to the chest. The patient was closely watched, yet the symptoms gradually increased in severity. On the third day, syrups, ipecac, and liquorice were given in combination, and powders, composed of Dover's powder, quinine, and small doses of the chalk and mercury mixture, were added to the treatment. The symptoms still in- creased in severity ; though the skin was moist, the cough was troublesome, the pulse very frequent,—from 139 to 140,—and unpleasant head symptoms began to manifest themselves. The ipecacuanha was abandoned, and the iodide of potassium was substituted, and wine or brandy was soon super- added to the treatment. In spite of treatment, great prostration came on ; the pulse was very feebie, and so frequent as to be with difficulty counted. The patient was seemingly unconscious of all surrounding objects; a con- stant moaning was kept up, the arms were constantly sawing tho air, mus- cular spasms were occasionally observed, and the eyes were cither strongly drawn to one side, or strabismus was added to the list of ominous symptoms. 126 APPENDIX. The eyes were generally open, yet at times there was no evidence of seeing. The pupils were sometimes greatly dilated, and at others as prcternaturally contracted. The pectoral symptoms were upon the decline, the cough was less, and the physical signs gave evidence of an abatement of the original disease ; yet all hopes of a favorable issue grew less, day by day. A blister was applied over the cervical region of the spine, and croton oil over such places as had been the more common sites of the former cutaneous disease, with the hope of establishing an eruption, not unlike that which, for two or three weeks, had passed away. Iodide of potassium, quinine, small and frequently repeated doses of opium, for its stimulating effect, were con- tinued, and milk punch and beef tea were administered liberally. On the evening of the 23d, the eighth day of treatment, we left our little patient, informing the mother that death would probably end the child's Bufferings before morning. It was with much sorrow and regret that wc gave this unfavorable prognosis. The parents were our intimate friends, and the patient was an only child. If other influences were wanting to nerve us to the fullest extent of our energies, it might be found in the fact that, though in active business for more than two years, we had not lost a patient under sixty-five years of age, and we were desirous of protracting that interval to the utmost. On our way home, wc mentally reviewed the symptoms and the treat- ment, from the beginning. That the pneumonia was gradually subsiding there could be no doubt. It was quite probable that there was no inflam- mation about the cerebral meninges, and that there was no effusion upon or within the brain. It was probable that the symptoms arose from anccmia, and that death was about to take place because the nerve-centres did not receive the requi- site stimulus. Yet what treatment, better than that in use, could be brought in requisition, unless Ave practiced transfusion ? A more decided nerve- stimulant Avas wanted. Was it to be found in our list of remedies? Strychnia Avas thought of; but could so powerful a remedy be safely administered, in a child so young, Avith hopes of beneficial results suf- ficiently speedily for our purpose? Reflecting thus, a conviction came over us, with the assurance almost of prescience, that the syrup of hypophosphites of lime and soda Avas the best remedy in the materia medica to meet the indication presented in the case under considera- tion. The brain and spinal marrow contain phosphorus largely, and it is quite probable that a remedy that Avill supply it, in an immediately available form, will supply the stimulus desired. So plausible was this reasoning to our mind, at the time, that we returned immediately, and in the darkness of a stormy night sought our little patient again. In addition to the treatment formerly advised, wc ordered five drops of the syrup of the hypophosphites of lime and soda, to be repeated every tAvo hours. We urged a persevering use of remedies, however discouraging the circumstances, until death or im- provement should take place. On the following morning we found our patient apparently somewhat fin- APPENDIX. 127 proved. The moaning was less, the strabismus and spasmodic. drawing of the eyes to one side had passed away, and the sawing the air Avith the hands was much diminished. Though the prostration wasgreat, and the symptoms still very alarming, yet the general expression was one that gave us reason to hope for a favorable issue. The treatment Avas continued, and the patient made a rather sIoav but perfect recovery. We are aware that any conclusions drawn from one case would be as likely to be false as true, and our readers arc left to draw their own conclusions from the case. The reasonableness of the treatment of hydrocephaloid disease Avith the hypophosphites, connected with the prompt and satisfactory result in the above case, have induced us to report it. Subsequent experience, only, can determine the value of the remedy. STATISTICS AND GEOGRAPHY OF CONSUMPTION. (Read before the New York Historical Society, by II. D. Millard, M. D.) It has been estimated tliat about one-sixth cf all the deaths among the human race occur from consumption. .In New York city it destroys one-third more lives than all the other dis- eases of the respiratory organs, such as bronchitis, congestion, and inflammation of tho lungs. catarrh, and influenza, whooping cough, asthma, &x. No climate is exempt from its sway, but it exercises its remorseless rule ia tho frosty climes of tho north, ia the scorching heats of Africa, and in the more genial atmosphere of tho temperate zones. In using the word " con- sumption," the speaker said ho referred to that variety of phthisis characterized by a deposi- tion of tubercles in the respiratory organs. Dr. Caspar, in 1847, from a table of C0,000 deaths, occurring from various diseases within twenty or thirty years, found that the ratio of deaths by consumption, to Iho deaths from other diseases, was as one to five seven-tenths. Ho (the speaker) had found, from a table he had lately constructed, that of 2,771,728 deaths from all diseases, between 1804 and 18C0, 4S3,588 deaths, or one in five seven-tenths, were caused by consumption. Theso deaths occurred in almost every variety of climate. There aro some countries in which consumption is entirely unknown. Thero has been no material increase or diminution of tho disease. Statistics of the city of London, kept for 230 years, show that from 1629 to 1740 it caused 6 6-10 part of all the deaths, while from 1740 to 1S30 it caused 4 6-10 part, or nearly as many more. Since 1830, however, the deaths have seldom exceeded 1-6 part of tho whole. In New York; from 1804 to 1820, the deaths by consumption wire one in 4 2-10 ; from 1820 to 1S35, one in 5 4-10 ; from 1835 to 1850, one in 6 5-10 ; and from 1848 to 1859, ono in 3 46-1C0. There is no doubt that it has steadily declined since 1S05. In Boston, from 1810 to 1818, the deaths by consumption were about one in 7. Since then there has been a gradual decrease, till 1845, when it caused about one death in 6 6-10. While consumption prevails hero to such an alarming extent, in England, where a more equable climato exists, tho proportion of deaths from this disease is muchhighcr than in America. This might,how- ever, be owing to the humidity of tho atmosphere there. Hero temperature, or the dif- ference of a few degrees of latitude, has little to do with its prevalence. In New York city, which has a mean annual temperature of 50 degrees, the deaths are one in 8 46-100 ; while In Charleston, which is situated 8 degrees further south, and has a mean annual temperature of 64 degrees, they arc ono to C 7 10. In Philadelphia, with a mean annual temperaturo of 128 APPENDIX. nearly 54 degrees, tho deaths by consumption arc one in 8 9-10. In Providence, with a tem- perature tho same cs New York, tho proportion is one to 6. In Chicago it is ono to 10. In New Orleans, which has a moan temperature of C7 degrees, tho proportion ia 1850 was ono in 11 7-10. In Memphis, in 1859, it was one to 11 3-10., And in Brooklyn, from 1848 to 1S59, it was ono to 8 11-100. In tho United States army thcro are about thirteen cases of consump- tion to every thousand men. The greatest number of cases occur on those posts located between 26 and 35 degrees of longitude ia Alabama, Florida, and Mississippi, including the cities of Charleston and New Orleans, which aro characterized by high temperature and excessive moisture. Tho stations in Texas and California shew tho smallest proportion of deaths from consumption. Trobably tho smallest proportion of cases anywhere in tho United States is in New Mexico, whoro tho deaths arc only about 1 3-10 in every thousand men. High elevation, cold equable climate, arc not calculated to the large development of consump-' tion. The regions of the high latitudes enjoy almost entire immunityfrom the disease, and in Iceland and among the Esquimaux it is rarely if ever known to occur. It is also a rare dis- ease in Upper Russia and Western Siberia. In Alexandria, situated in the 31st degree cf lati- tude, with an atmosphere saturated with saline vapor, consumption is almost wholly unknown ; and in Teheran, Persia, situated in latitudo 05 degrees, with an elevated position and rarifiad air, is very rare. Tho medical statistics of the British army afford much valu- able information in regard to tho prevalence of the disease in different parts of tho world, and give a correct impression in relation to the influence of certain varieties of climate. From these we find that in tho United Kingdom 5 5-10 men in a thousand were attacked by consump- tion. In tho West Indies, between tho 10th and 19th degrees north latitude, there were twelve in a thousand. Theso returns show how erroneous arc the views generally entertained in regard to the influence of the climate of the V.'est ladies, or of a warm climate, per sc, in arresting the developments of consumption. In two of the stations of the Mediterranean. namely, Gibraltar and Malta, long noted as salutary retreats for consumptive patients, it is actu- ally more prevalent and fatal than in Canada and Newfoundland, with their long, cold winters and vicissitudes of climate. In Canada, 6 5-10 per 1,000 men arc attacked, and 3 8-10 die of the disease. In Gibraltar 7 aro attacked, and in Malta 6 7-10. In Bermuda, with a great uniform- ity cf climate, 8 per 1,000 men arc attacked, and G-10 die ; while in Newfoundland the deaths arc only 4 per 1,003. AVhilo on tho ono hand, therefore, consumption is rare or unknown in those countries situated in high latitudes, wo And that it frequently exists in its minimum among these living \:\ tropical countries. In all India, out of ten regiments, the aggregate strength of which was nearly 15,C00 men, during a period of fourteon years, only forty-throo were attacked. Madeira, between the 32d and 33d degrees of north latitude, with its balmy atmosphere, perpetual summer temperature, tho thermometer showing a variation only of ten degrees and tho mean annual temperature being 65 degrees, seems, of all the countries in the world| best llttcd for the mitigation and arrest cf consumptive conditions. Patients who come hero llvo three or four years longer than the ordinary duration of the disease in England, and large numbers have resided in tho island ia perfect health, while their brothers and sisters have fallen victims to tho disease at home. Havre, situated near tho sea, with a free circula- tion of air, is nearly exempt from the disease. At Rome about one-twentieth, and at Naples one-eighth of the deaths occur from consumption. Tho theory that tho sea somotimes acts as a preventive or palliativo of consumption is confirmed by statistics. Out of an aggregate English naval force of 12,942, in the Bay of Bengal, in 1842,39 were attacked, and 16 died of consumption. In an aggregate military forco of 14,590, on the Island of Ceylon, in the samo latitude, 7S-just double the numbc.-T. were attacked, and 51 died. From 1883 to 1S30, of an effective total of 159,770 British sail- ors, stationed in every part of tho British dominions, from tho Capo of Good Hope to North America, tho deaths by consumption were 1 7-10 per thousand men. In tho British army tho number of deaths per thousand by consumption is 4 9-100 per thousand. Dr. Caspar, from tho tables kept at Berlin, shows that the difference ia mortality from con sumption, in various winters, has no connection with tho difference in temperaturc-in tho coldest and tho warmest weather the mortality being the same. In a table of 212,407 deaths APPENDIX. 129 from consumption ia tho principal cities of tho world, tho deaths were—;a the spring, 01.945 , winter, 65,3:9; autumn, 45,953. Consumption is not necessarily more prevalent ia largo than ia small cities, though the rural districts arc less liable to Us development. Consumption is a rare disease among African negroes, but tho p-edisposition is increased when they leave homo. Tho proportion of deaths among gentry and professional men is 10 ■ among tradesmen 28 ; and among laboring men, CO per cent. Among pressmen ia printing-offices, SI per cent, die of consumption, and of those conflned m unvarying position, 71 per cent. From the various facts presented the speaker deduced tho following conclusions : 1. That climate is the most powerfut agent in modifying and controlling its prevalence. 2. That there aro certain varieties of enmato inimical to the development of consumption, and of these tho most unfavorable arc. arst—those characterized by extreme and varying cold second—climates characterized by a cool, Iry atmosphere . third—those which liavoa very hi^h temperature with but a moderate amount of moisture. 3 That those climates most favorable to consumption are those which have a high tem- perature and moist atmosphere, and those which aro characterized by great variations ia the daily temperature. Humidity seems most favorable, and dryness most unfavorable to con• sumption. 4. That tho liability is increased by insufficient exercise and conflned air. 5. That it is more prevalent among females than males, on iaad than on tho soa, and that tho period of its greatest mortality is between the ages of twenty and thirty. TONIC PROPERTIES OF HYPOPHOSPHITE OF QUINIA. By Ar.cms B. Cooke, M B Demonstrator of Anatomy, Med. University. Louisville I inscribed this remedy ia three cases of phthisis. The first case was in the last stage of the disease, very much emaciated, with hectic, and colliquative diarrhoea 1 ordered on the 5th of June hypophosphite ot quinia 'a five-grain doses, three times a day. dissolved in dis- tilled water. Tho remedy was continued as directed, with apparent benefit, until tho 12th, when he complained of tightness or distension ;n the head and ringing and buzzing in the ears These symptoms began to manifest thcmsc.ves tho day previous, but were not fully developed until the 12th. Ho had, in seven days, taken 1C5 grains On the sixth day of exhibition he had symptoms of qumlnism , on the scventn he was unmistakably cinchonized. The remedy was then suspended for two or three days, and again resumed in the two-grain doses, three times a day In the latter part of tho month he had an attack of acute diarrhoea, which, with the hot and oppressive weather, again prostrated him. During tho uso of the remedy he felt better, complained less of indigestion, had a better appctito and less hectic. Ia tho other two cases, ia which tho disease had not so far advanced, tho remedy, admin- istered ia doses cf two and a half grains, three times a day, acted as a good tonic, in conjunc- tion with cod-liver oil * As a toaic, stomachic, and aati-hectic, I would give the preference to the hypophosphito of quinia. I had not an opportunity of testing its effects in an uncomplicated case of intermittent or remittent fever ; but,.judging from its prompt constitutional influence, in tho first case in which it was administered, I would havo confidence ia its anti-periodic powers, and think it mi.-rht be safely substituted for quinine, especially in cases of constitutional idiosyncrasy, or ::i chronic cases, whero tho sulphate has been taken ia largo quantities. In convalescence from acute diseases, and ia acute cases occurring in miasmatic districts, where anti-periodics form a necessary part of the medicinal regime, this new preparation might bo used with much ad- vantage—'Louisville Medical News. * Sco paga 3, General Circular, on tho uss of Cod-liver oil ia Consumption. THE HYPOPHOSPHITES IN CONSUMPTION AND COG- NATE DISEASES. There can no longer remain a reasonable doubt of tho therapeutical value of the Hypophos- phites in the treatment of Consumption and cognate diseases, since the very general test to which they have been subjected during the past two years, and their rapidly extending ap- preciation by the profession, both in tho Old World and ia the New, establish them amongst tho most important contributions which have been made to Materia Medica during tho last century. It will not have escaped the attention of tho careful reader of tho Treatise, that, in all cases where pure preparations of these salts have been used, their effects have been prompt and radical . so that the physician who has most extensively exhibited them in his practice, has commended them with most enthusiasm, and has been most astonished by the happy ro- sults of his experiments. It is a complete answer to the cavilers at '• new things," to point to these numerous cases 03 they so fully establish the extraordinary power of the Hypophosphites, when pure, over tho tubercular condition, that they cannot fail of impressing upon all minds the manifest truth, that the failures which have been imputed to the remedy, arc duo solely to the meretricious compounds prepared by ignorant or mercenary apothecaries and chemists. The c ses em- bodied in this appendix, it should be stated, arc but types of several hundreds which are con- tained in an extensive business and professional correspondence. An exhaustive statement of tho evidence from this single source, would fill a considerable volume by itself ; but, as Dr. Churchill has observed (Ante p. 9)," it is not so much the num- ber cf favorable cases as it is their relative agreement which gives weight." But it is not strange that unfavorable results should sometimes get reported to the journals, when wo consider the shameful circumstance that, in Boston, New York, Philadelphia, Cin- cinnati, Chicago, St. Louis, and New Orleans, and in many places of less note, some of tho most prominent apothecaries have not only made combinations of the Hypophosphites, which aro explicitly condemned by Dr. Churchill (Iron especially), but they have, with a wanton ignor- anco of the authority which they thus repudiate,printed it upon their labels that tho remedy wag " discovered by Br. Churchill OF DUBLIN ! I " Br. Churchill " of Dublin" is a distinguished writer upon Obstetrics, but he is not entitled to tho distinction of having made the new discovery in Therapeutics. In the light of such disclosures (which may be verified by the reader with little trouble), it ceases to bo matter for surprise that the treatment which was supplied from such sources failed of that consummate success which has uniformly attended tho exhibition ofareliablo preparation. The attention of tho reader is called, in this connection, to the statements of Dr. Churchill, at pp. 80, 81,95, 96, and 101. These citations will show of what vital necessity tho Author esteems the purity of the salts, and this necessity can not ho too frequently nor too deeply impressed upon the mind of the profession. , It explains every apparent failure, and shows that no negative conclusion, based upon experiments in which so essential a condition of success has been neglected, is of tho least value. The failure to observo this condition, indeed, would havo afforded a sufficient reason for rejecting tho Reports of the Brompton Hospital, even if thcro were no other grounds (such aa APPENDIX. 131 havo been shown), for regarding them as utterly without weight In determining the valuo of tho new remedial agents proposed by Dr. Churchill. REPORT OF CASES BY W. W. TOWNSEND, M. D. Chatham, Pa. , 3d Month, 25th, 18C0. I i:ik.vi) J. Winchester :—At the time cf receiving your letter, requesting a report of the cases ia which I had used the Hypophosphites, I was very much engaged both night and day. Wo "have an epidemic of typhus fever, commencing last July, which has occupied all my time and attention. Many of the persons who have taken the Hypophosphites have not been under my immediate care but most Df the cases I have had an opportunity of examining, previous to their commencing the treatment A detailed account of each case would bo very interesting and instructive. This, however. 1 am anabio to give, except in very few cases Thirty-six persons havo obtained tho medicine from me, twelve ol whom havo been under my own care Five of them were. In my opinion, and in tho ludgment of other physicians, hopeless cases cf phthisis, with irritable cough, copious expectoration of a purulent character, night sweats, and emaciation Tliese cases wcr: from one If- three years' standing Auscultation and percussion developed sounds, which, taken in connection with other symptoms, gave evi- dence of a condition from which I HAVE NEVER, ire zcventcen years' practice, SEEN A SINGLE CASE RECOVER BY ANY OTHER TREATMENT. Th; usua. dose was from five to ten grains a day None of them havo taken over three of tho largo bottles. Under the use of tho Hypophosphites, all the bad symptoms ceased, they havo gained flesh, and strength, and health—some of them better than they had enjoyed for seven years previously. Tho other cases under my care were in the incipient stage, and, ia theso, all symptoms or traces of the dijease have disappeared. Of those who were not under my care, 1 have not heard of a single patient who did not express himseli benefited by the use ~.f the Remedy, although in somo of them tho disease was too far advanced to admit the possibility of recovery. t presume I am as skeptical la medicines or specifics as most physicians : yet, from tho experience I have had .a the use of Dr J. F. Churchill's Remedy for Turerculosis, I would say to all to/to have any tendency to that disease: Take it, and the sooner tab better, beforo there is disorganization * * * W. W. TOWNSEND, M D. P. S.—If the foregoing, or any part of it, is of any uso to you, you may publish it in con- nection with my name, if you sec proper. FURTHER REPORT FROM DR. TOWNSEND. Additional Cases—ItoinarLable Results. Chatham, Pa., 6th Mo. 12th, 18C0. Friend J. Winchester :—Having obtained from thee a considerable quantity of Dr. Church- ill's Remedy for the Cure of Consumption, which I have used to some extent ia my own prac- tice, and dispensed to others, . feel it to bo duo to the community to state the results, so far a.s the cases have corao under my owa immediate notice, or I have my information from reli- able sources. CASE I.---------, agod 47 married • born in Chester county. Had a decided tubercu- lar taint from his mother, who, togethor with all her brothers and sisters, died of phthisis. During the winter of 1351-2, ho had a severe and protracted attack of typhoid fever, since which time his health has boca on tho decline. Took cold oa the slightest exposure cough and expectoration • pain ia the left side of tho chest • frequent chills: pains of a neuralgic character in various parts of tho system . pulsa becoming more aad moro frequent; loss of flesh an I strength , increasing dyspnea [difficulty of breathing': on tho slightest exertion ; frequent attacks of haemoptysis [bloedmg of the lungs'] , percussion elicited a dull sound, and tho respiratory murmur very indistinct. Although a very active business man, he had been compelled to relinquish ail business. 132 APPENDIX. Diagnosis.—Tubercles in the first stago of softening ; which was confirmed by the opinions of two eminent physicians of Philadelphia. i directed him to take tho Hypophosphites, commencing with one teaspoouful in the morn ing, and gradually to incroase the dose. He was not able to increase tho doses to moro than ten grains, or to continue tho uso of the remedy constantly without increasing the hemorrhage. The exact length of timo ne remained under treatment, or the total quantity he has used, I am not able to state, as I did not see mm regularly. But this 2 know: HE HAS REGAINED HIS HEALTH, and is now engaged in a laborious and fatiguing occupation. CASE II. —— ——, married .; aged about tO Thi3 patient had, in February, 1858, a severe attack of pneumonia, from which he did not wholly recover , left lnng dull on percus- sion, and tho respiratory murmur scarcely audible. During the following summer, he was subject to frequent chills took cold on the slightest exposure, or change of weather ; cough very troublesome,especially in the morning In tho courso of the following winter :1859). he commenced to expectorate a substance of a mucopurulent character ; lost licsh and strength ; pulse quick and jerking ; night-sweats ; with a slight rhonchus, or sub-crepitous sound upon auscultation. Diagnosis —Tubercles in the first stage of softening, He now commenced tho use of your • ■ Preparation of tho Hypophosphites,'' in doses of five grains, twice a day, which was continued, with short intervals, until ho took nearly two bot- tles of the large size, when not a vestige of the bad symptoms ,'bcfore stated) could be discov- ered, ALL PHYSICAL SIGNS HAVING ENTIRELY DISAPPEARED. Over a year has now elapsed, and he still retains his health and strength. To use his own language : '■ I have better health since 1 took '.hat medicine than for several years previously. I AM WELL. There is Blood in that Medicine " CASE in. ——----; aged 25 years unmarried. This patient came to mo from a dis- tance. Hs was pale and emaciated, frequently clearing out his throat, said his cough troub- led him very much at night. that he had pain m bis breast and under his shoulder-blades, and was often very hoarse . that his health had beon rapidly declining for about six months : was of a consumptive family ; has had several attacks of hemorrhage . very short of breath on the least exercise ; pulse 120, and weak. Upon examination, I found a sub-crepitant rhon- chus throughout the bronchial tubes ; percussion dull. Diagnosis —Tubercles ia both lungs ; and that he was about to have an attack of hemor- rhage—which soon after occurred. After the bleeding had ceased. I advised him to tako tho Hypophosphites. I did not soo him again for three months, when ho again called upoD me. He had used, during this period one large bottle of the Hypophosphites , and had gained twenty pounds in flesh. Pulse 80 ; per- cussion and auscultation discovered lio unhealthy nor discordant sounds. He said his appetite was good, and that he felt as well and as strong as he ever did before. His appoarance fully corroborated the truth of this assertion. He has passed the winter since I saw him and I learn that he still retains his health. I might extend my report by the statement of many more cases of (to myself) equally surprising recoveries from tho use of this Remedy; but it would be simplv useless to repeat what is already given. / have no doubt, whatever, of the superior efficacy of the HvropHospirrrES in the treatment of Tuberculosis, OVER ALL OTHER MEDICINES, OR METHODS, HITHERTO DIS- COVERED. I repeat what I said in a former communication, that / know of no medicine or treatment with which I have ever seen effected in this fatal malady anything more than a-mitiga- tum. Yet, in simii^r cases, under tho uso of Churchill's Hypophosphites, as prepared bV your- self, I HAVE SEEN MANY RESTORED TO THEIR USUAL HEALTH AND VIGOR. I do not wish to be understood as saying that this Remedy will euro in all cases or stages of Consumption. It is not, as many suppose, merely necessary to obtain tho m-dicine and take ,t under all and every circumstance. On the contrary, ,t ought to bo administered tinder tho direction and care of an honest, intelligent physician, who is the best judge as to tho quantity, and also when to tako the remedy and when to cease. Without this intelligent super vision, many cases will fail to be benefited that otherwise might have a different result APPENDIX. 133 1 would here remark, that I have met with several invalids who told me they had been taking Churchill's medicines, who failed to receive any benefit whatever. Upon examination I found that ono obtained a preparation made in Cincinnati, Ohio, and another in Wilmington, Del., both of which were entirely different from your " Genuine Preparation." One of these spurious articles, proved to be Prof. Jackson's Phosphates of Lime, dx , and the other had a combination of Iron, of which the patient took a table-spoonful three times a day, without the least vlsible effect 1 I mention these facts, within my own knowledge, to GUARD PATIENTS AGAINST IMPOSTURE. In conclusion, I repeat that I might report many additional cases, of which those given are a fair typo, of the results obtained by your Hypophosphites. I can state that over sixty per- sons have obtained the remedy from me, and of the entire number, I cannot turn to a single caselhat lias not been benefited by their use. Several were in the last etage ot disease, when no curative progress could be looked for ; yet, even in these the patients expressed themselves relieved. In those which terminated fatally, there was an improvement of strength, increase of nervous force, stoppageof night-sweats, and amelioration in the general symptoms ; so much bo, insomo instances, that both the patients and their friends were disposed to hope against my certain conviction and better judgment. 1 havo had many letters addressed to me, from different sections of tho country, since your publication of my first brief report, and patients have come from considerable dis- tances to consult me in regard to the treatment. ************ I am, very respectfully, your friend, W.W. TOWNSEND, M. D. REPORTS FROM NEW ENGLAND PHYSICIANS. New England Agency Office, Boston, June 22, 1S60. Dear Sir : Dr. Benjamin Weeks, of this city, who has taken a very deep and patient inter- est in collecting the opinions of his numerous professional friends in New England, as to tho value of the Hypophosphites in PlUhisis and Tuberculosis, has generously permitted me to abridge a portion of tho following report from his note-book. For the most part, tho notes of Dr Weeks were collected, ho informed mo. during tho months of January and May last; and arc chiefly a record of informal verbal communications, divested of technical precision : and, though freely given, not designed to bo presented as scientific reports of the cases to which they refer. Perhaps, on this very account, they are the more valuable, as embodying unreserved ex pressions of professional opinion. Too frequently, also, it is tho case, that a report designed for the Scientific Convention is so overlaid with exceptions and qualifications, as to make it difficult to discover precisely what arc the real opinions of its author upon tho subject which ho discusses. I trust, therefore, that whatever may be the supposed deficiencies of the report, tho gee- tlenien named in it will not be held responsible for them. Boston, Mass.—Dr. Benjamin Weeks, recently used "Winchester's Preparation" in two cases of Laryngeal and Bronchial Phthisis : The first—a scrofulous and feeble patient, still more debilitated by a recent abortion, with attending hemorrhage and harassing cough—was cured by the use of a single large bottle. The second case—affecting the upper portion of tho lung, accompanied with severe cough, hectic, dysmenorrhoea, a general nervous debility and prostration—has greatly improved, and is nearly recovered under the use of the second bottle Dr. Sunderland has prescribed the Preparation in several cases. He reports two cases of great nervous debility and prostration. One was accompanied with chronic inflammation of tho bowels, which had long resisted other treatment, under different physicians. Both patients were cured in a short time by the use of the Hypophosphites. Dr. Weld, of Jamaica Plain, is using it extensively " with success." Dr. Morris Mattcson has used the remedy in his own case, and is " highly pleased" with it. 134 APPENDIX. Many of tho leading physicians ia Boston hjvo obtained ''Winchester's Preparation," most, if not all, of whom, aro now using it in their practice in preference to any other prepa- rations of the Hypophosphites. Among these, I may mention Drs. Thayer, McFarlane, Ware, Garret, Warren, Smyth, Pinkerton, Fuller, Goulet, Leo, and others And in the vicinity of Bos- ton,are Drs. Parker, of Melrose , Swan, of Dorchester ; Fenlon, of Newtonville ; Salisbury, of Brookliue ; Thinney, of Melrose ; Babbitt, of Quincy ; Warfleld, of Holliston ; Whitney, and others, of Framingham. Lawrence, Mass.—Dr. Geo. W. Garland states that he commenced by using the Hypophos- phite of Lime. He at first gave it in a case of Tubercular Phthisis, far advanced in the stage of softening ; with frequent hemorrhage, purulent expectoration, and great emaciation. Tho case had resisted the ordinary treatment, and was considered hopeless. He commenced using th remedy in January last, when an improvement was soon perceptible, and now (23d May, 1S60) tho patient has every appearance of perfect health. Dr. G. also states that ho pre- scribed it in the case of a lady, who had recently aborted, who had profuse hemorrhage, and wh» had also an alarming and harassing cough, was anemic, and exhibited great emaciation and debility. Under the use of the Hypophosphites sho perfectly recovered. Mr. II. M. Whitney druggist and apothecary, at Lawrence, gives the case of a young man in the last stage of Consumption, who had taken five bottles ot Nichols' Hypophosphites* (containing iron, &c ), with no benefit, and who, by tho advice of Dr. Howe, has since used "Winchester's Preparation," "with decided benefit." Thinks he will recover under its use. Though the case was considered hopeless, the remedy has had a " wonderful effect." Haverhill, Mass.—Dr James C. Howe states that his wife had hereditary Tubercular Phthisis, far advanced, with frequent hemorrhages from the lungs. He used the ordinary tonics, &c. .including several bottles of other preparations, which only served to incrcaso tho hectic and other troublesome symptoms. She was much emaciated and very feeble, when sho began the use of "Winchester's Hypophosphites of Lime and Soda." Improvement wxs at once perceptible, which continued, and now (May, 1S60) SHE IS WELL, and is freefrom all the signs of Phthisis- Dr Howo has also used it in several cases of Phthisis, of less severity, as also in Anemia, with the " happiest effects." Dr. B. E. Sawyer is prescribing it extensively in his practice, and with "satisfactory results." Dr. Kendall Flint and other physicians in Haverhill are also using it, and speak of it in terms of commendation. E. G Frothingham, Jr., druggist and apothecary, of Haverhill, writes,under date May 4th, 1860 : "lam fully convinced of tho great value of Winchester's Hypophosphites in Pulmonary affections, both from accounts given mo by several physicians, aad by several cases which have come under my own observation, two of which were considered hopeless, and both of which are now improving." West Amesbury, Mass.—Dr. Pattee reports a case of Phthisis and Marasmus, of long stand- ing. The patient, a girl of twelve years, was reduced almost to a skeleton. Various remedies were used with no beneficial results. Fivo bottles of other Hypophosphites had been administered, but they seemed only to increase tho hectic symptoms. Dr. P. finally ordered " Winchester's Hypophosphites of Lime and Soda," and, under the use of two bottles, sho was entirely cured. South Royalston, Mass.—Dr. J. B. Gould writes, under date January 9, 1860 : " I have used the Hypophosphites somewhat in my practice, but not Winchester's Preparation. I wish now to compare his with other preparations." And again, as to the result-, under date February 6, I860, he writes : " It is giving a high degree of satisfaction." * In several of the above cases, it is stated that the physicians prescribed certain prepa- rations of the Hypophosphites, containing iron, before "Winchester's Preparation" was known to them, and that the change from the former to the latter was invariably marked by a rapid improvement in the patient's condition. Tho iron salt, as migtit have been anticipa ted, always aggravated the inflammatory symptoms ; while theso symptoms disappeared un- der the use of the Lime and Soda. Some of these statements have been omitted to avoid repetition. See pp. 79,101.—[Publisher. APPENDIX. 135 New Bedford, Mass.—Dr. Chas. M. Tuttle states that he knows of no remedy equal to the Hypophosphites in Pulmonary diseases, Chlorosis, Anemia, kc. Has been prescribing it for several months, and should be " unwilling to do without it in his practice." Fall River, Mass.—Drs. Fiskc and Clarke are using « Winchester's Preparation," and re- port it " working well." They are not yet ready to report in detail. Taunton, Mass.—Dr. S. P. Hubbard is using it a good deal. He formerly prescribed another preparation, but now considers Winchester's superior. Grafton, Mass.—Dr. F. A. Bosworth has used it much " with invariably satisfactory re- sults." Concord, N. H.—Dr. James E. Sargent says the preparation answers his most sanguine expectations. He relates a case of Abcess in lower part of right lung—a case of Phthisis Pul- monale. It was long in developing, buj finally discharged profusely. The patient was much emaciated, with severe cough, hectic, and all the symptoms of Phthisis. Immediate Im- provement was manifest under the use or the Hypophosphites of Lime and Soda. Dr. a re- ports the patient now in perfect health. Dr. Geo. Warren Smith, of Concord, writes under date May 28, 1860: "I have used ' Winchester'* Hypophosphites' in several cases of Phthisis. In each case the cough subsided, the respiration improved, and the bulk of the body was in- creased. I have also used them in Chlorosis with marked success." Dr. A. Morrill Concord is using them with good effect. Ho is now prescribing it in two cases of phthisis far advanced. He thinks they have prolonged the lives of these patients through the winter, and both are now improving, with a fair prospect of recovery. Dr. E. G. Moore, also of Concord, has prescribed the preparation in many cases of pul- monary and other affections, '• with very good results ;" especially so in a caso of Aithisla Pulmonalis, with abcess, which is fast recovering. He will report this and other cases. He holds the remedy in " high estimation." Dr. J. M. Graves, Concord, has prescribed it generally," with satisfaction." He mentions a severe case of TubercuUxis, where the remedy gave relief, but fears the disease is too far advanced to admit of recovery. Drs. Timothy Haynes, Ezra Carter, and others, of Concord, are using it with " excellent results." Dover, N. H.—Dr. Chas. II. Horsh has prescribed the Hypophosphito of Limo in two cases of Tubercular Consumption, both too far advanced to anticipate a cure. In one case, the remedy gave considerable relief: in the other, but little—thinks the lives of both patients were prolonged by its uso—but both diod. Also administered it in two cases of chlorosis— one, accompanied with profuse Leuoorrhcea, Dyspepsia, and Gastralgia. Both patients wore much emaciated, both immediately improved under its use, and both entirely recovered in a very short time. Dr. H. has used it in several other cases of more or less severity, and be- lieves the remedy '• an important addition to the Materia Medica." Dr. A. J. II. Buzzell, of Dovei:, is using the preparation in a marked case of Tuberculosis, far advanced. The patient has been under the treatment four or five weeks ; has rapidly improved, and now has a fair prospect of recovery. Drs. A. Bickford, P. A. Stackpolc, L. G. Hill, and others, of Dover, arc prescribing it " with good effects." They intend testing it fur- ther, and will report, Nashua, N. IL—Drs. E. & E. Colburn arc using the Remedy, and think well of it. Dr. J. C. Graves is using it with " complete satisfaction." Dr. Woodbury is " well pleased with its effects, both upon himself, and Patients." Dr. Geo. Gray has prescribed it" in many cases ;" has several now under treatment, and believes it '■ an excellent remedy for that class of Dis- eases for which it is recommended." Dr. I. II. Gibby is prescribing and selling the Remedy, and speaks decidedly as to its value. Nearly or quite all the Physicians in Nashua are using " Winchester's Hypophosphites," and assert, in general terms, their beneficial effects. Great Falls, N. H.—Dr. Chas. T. Elliott gives Winchester's Hypophosphites great praise. Has prescribed it in several cases of Tuberculosis," with entire success.'' He mentions onecase, in particular, in the town of Rochester, where he was called in consultation. The case was considered incurable—all tho usual remedies having failed. Dr. E. advised the Hypophos- 136 APPENDIX. phitcs—" Winchester's Preparation." The patient began to improve, and, to the surprise of all,both Thysicians and friends, is now well. Dr. E. reports him "entirely recovered." Dr. E. has also used it ia Chlorosis. Anemia, !:c., with like results. He will report these, and other interesting cases, in full. Dr. Chas. H Shackford, of Great Fails, is prescribing it ex- tensively, and with "satisfactory results." Drs J. C. Hanson, Frank Tuttle. Edward H. Pratt, and others, cf Great Falls, speak ia flattering terms of tho effects of the Remedy in rhthisis, and cognate Diseases. Franklin, N. H.—Dr. K. L. Knight thinks it " the best remedy he can prescribe in Pulmo- nary Diseases." Mason Village, N. H.—Dr. Edwin Schofield is using it, " with the desired cffjcts.'* As the above report is intended to embrace only '3 Wharo tubercle already exists, alcohol has no effect ia modifying tho «sual course run by that substance. "4. Neither does it mitigate the morbid effects of tubercle upon the system, in any stage of the disease.'' APPENDIX. 141 RELATION OF ALCOHOL TO DISEASIl.-Chemical experiments havo demonstrated that tho action of Alcohol on the digestive fluid is to destroy its active principle— the pepsin; thus confirming tho observations of physiologists, that its use gives riso to tho most serious disorders of tho stomach, and tho most malignant aberrations of tho ontiro economy. It is evident that, so far from being tho conservator of health, Alcohol i3 aa activo and powerful causo of disease. Interfering, as It docs, with tho respiration, tho circulation, and tho nutrition, how is any other result possible ? Nothing can bo moro certain than that: It is a powerful antagonist of the digestive process. It prevents the natural changes going on in the blood. It impedes the liberation of carbonic acid—a deadly poison It obstructs the Nutritive and Reparative functions. It produces disease of the liver. It has a powerful affinity for the substance of the Brain,—being, indeod, essentially A Brain Pobon. [Alcolwl and the Constitution of Man, by Professor E L. Youmans.] Published by D Applcton & Co , New York. *■ ---------«i-o^t>--------- DANCER OF IRON IN CONSUMPTION AND CHLOROSIS. In a succeeding edition of tho Treatise, wc design publishing—if by any means it can be obtained—a full report, or synopsis,of the discussion, in tho course Of which M. Trousseau pronounced his remarkable opinions. No doctrine has been announcod, during tho present contury, that deserves, or that will receive, profounder attention from tho profession, than that which is here published : '• M. Trousseau has just given utterance to an authoritative and positivo statement, which will, no doubt, surpriso tho profession everywhere. He declares that iron, ia any form, given in chlorotic affections, to patients in whom tho consumptive diathesis exists, invaria bly fixes that diathesis, and hastens the development of the tubercles. The iron may iaduco a fac titious return to health , tho physician may flatter himself that he has corrected tho chlorotic condition of his patient ; but, to his surprise, ho will find tho patient soon after fall iatoa phthisical state from which there is no return This result, or at least its hastening, M. Trousseau attributes to tho iron. Tho assertion is a most startling one M Trousseau is nevertheless, so certain of what ho says, that ho denounces tho administration cf iron in chlorosis as criminal in the highest degree."—Mad. Correspondent cf the AT Y Times, in Paris. ON THE HYPOPHOSPHITE OF MANGANESE. BY W. ELMER, M. D. The functions of the glandular system, as well as the lymphatics, aro at fault in Consump- tion ; and henco tho noccssity of agents capable of influencing these functions. For this roason, Manganese is an important agent in tho treatment of Consumption. In its action, Manganese stimulates the glandular system, and quickens tho functions of tho lymph- atics and lacteals. Honcc, in our opinion, tho Hypophosphite of Manganese is most valuablo ia tho treatment of Phthisis and Tuberculosis. This salt, combined with others [Lime aad Soda?] is peculiarly advantageous, especially when there aro irritating cough and fever, and, we will add, is tho most valuablo preparation known in tho cure of recent coughs and incipient Phthisis, and may bo usod ia any Etago of the disease with beneficial results. Tho Hypophosphites of Limo and Manganese havo great merit. Wo havo usod them not only in Consumption, but ia recent coughs with much satisfaction.— North American Medical Reporter. 142 APPENDIX. THE TESTIMONY OF ENGLISH PHYSICIANS. Rcinarkfibl" Evidence of the Efficacy of the Hypophosphites. [At the very moment of going to press with this Edition of the Treatise of Dr. Churchill, I had placed in my hands, by the politeness of the Publisher Mr W. A. Townsend, the proof sheets of tho forthcoming number of • Erailhmatte's Retrospect of Practical Medicine" for July, 1S60, from which I republish the following highly interesting and instructive Reports. Theso Reports at once sustain the correctness and- illustrate the fairness, of the strictures upon the Reports of the Brompton Hospital. Indeed each of them as specifically contradicts the absurd assumptions of Drs. Cotton and Quain.as if it had been particularly designed tor that purpose But while these medical gentlemen are explicit and unequivocal in the testimony which they bear to the extraordinary therapeutical powers of the Hypophos- phites, they reveal a cautious conservatism in their conclusions which will make theirevidence all the more valu- able to the profession; because this very conservatism is a guaranty of the independence, aud an evidence of the integrity, of their observations.] The Hypophosphites in Tuberculosis, Debility, Strumous Dyspepsia, Loss of Appetite, «fcc. [Reported to the London Medical Circular.] I have now prescribed the Hypophosphites ia about twenty cases. They were in various stages of the disease, chiefly in the first and socond stages ; two were ia the third stage. Ono case has taken the remedy twelve months ; all the others about six months They aro still under treatment. So far from no physiological effect being produced, I have generally found, in each case, the following effects : A great increase of appetite , increaso of animal heat (in somo cases, not ia all) ; a marked diminution of the expectoratioa, in every case ;. the patients also expressing a feeling of improvement in their breathing power—that they could fill their chest better with air. On making an examination of the chest with the stethoscope, I have found the moist clicks to diminish in number ; in one instance, they disappeared entirely, and were replaced by vesicular breathing, perhaps somewhat harsher than natural ; this was an instance where the disease was of limited extent, in the upper part of the right lung, but, nev- ertheless a well-marked case. The hypophosphites appear to act as respiratory excitants; and I should certainly bo disappointed, upon testing their breathing power with the spirome- ter, if the volume of air inspired at each act of inspiration was not increased I havo not a spirometer, and, therefore, have not made the experiment; but, judging from the respiration becoming almost puerile ia some portions of the lungs, when, before its administration, the respiratory murmur was so feeble and indistinct as to be scarcely heard, and also from the loss of breathlcssncss experienced by tho patients themselves, I certainly should, from a con- sideration of the above phenomena, expect to find that such would bo the case Physicians connected with public institutions could easily settle this point. In October last, I gave a young man, aH. 20, five grains, three times a day He had all tho symptoms of phthisis , had diarrhoea ; was drenched with morning perspirations ; had no appetite ; aud his loss of flesh and strength was so rapid, that it threatened to bo a caso Of galloping consumption—there was unmistakable evidence of crude tubercle in the lungs When he had taken the hypophosphites for a month, his appetite became voracious; he gained weight at the rate of three pounds a weelc, for three successive weeks, and felt so strong and well that he resumed his work as a factory operative, and has continued at it until the present time. I saw him again last Saturday (February 25th) , he is now losing flesh, and has a dry cough, with partial aphonia—no night sweats ■ I advised him to rest, and resume the hypophosphites—with what results, time will shew. No other remedial agent was used in this case, except nutritious diet. A sister, aot. 25, of tho last patient, has persevered with the hypophosphites for twelve months. She has had chronic phthisis for five years ; it had boca kept ia abeyance by cod-liver oil, until twelve months ago, when, from somo unexplained cause, her digestive organs would not tolerate the oil any longer, when sho rapidly declined in health. I then gave the hypophos- phites. The improvement was more marked and permanent than ia her brother's caso. I saw her again oa February 25th, when sho expressed herself as being quite well —never better in her life. She had a robust appearance, and was very stout. All the general symptoms have disappeared. I had not an opportunity of examining the chest APPENDIX. 143 So far from no cfToct being produced, lam in the liabil of prescribing hypophosphites in any exhausted condition of the system where loss of appetite and debility arc the most prominent symp- torn!. Tho following caso briefly illustrates their utility in strumous dyspepsia, attended withde- bility : On Jane 14th, 1859, tho treatment with hypophosphites began , his weight was 137 pounds • no appetite, and weak. Juno 20th, 141 pounds. August 13th, 145 pounds-his appctito and strength keeping pace with his increasing weight. Oa January 14th, 1860, I gave the hypophosphites to a farmer, jet. 43, who had taken various tonics for a month, with no improvement to his appetite and strength On making an examination of his chest, I found evidence of a slight deposit in the upper part of the left lung He had gradually lost flesh, and had been troubled with dyspeptic symptoms for Fix months On tho administration of the hypophosphites, his appetite gradu- ally returned, and he began to gain weight, having gained four pounds in a fortnight. Surely here is evidence of some physiological power ? Tho largest dose I have given has been half a drachm [30 grains; a day, in doses of ten grains each. Very few cf my patients can talce more than five grains throe times a day, without producing headache and unpleasant feelings of fullness about tho head In one case, epistaxis came on All my patients took plenty of out-door exorciso when the weather permitted. No very satisfactory improvement took place in a less period than throe weeks. I should bo afraid to give a drachm-dose [GO grains] three times a day To recapitulate • I claim for tho hypophosphites a power of stimulating the appetite for /bad—which has taken place in evert cash . a power of rapidly diminishing the expecto- ration in all cases under my observation, and, in somo, completely arresting it ; a power of increasing the expansion of the chest; and, theoretically, of being respiratory excitants ; and they present us, at the samo timo, with " very efficient blood-generating agents '■ Mycxpe- rienco does not enable mo to say they cure phthisis ; but that they retard its procress, par- ticularly that of softening, I am quito convinced ; aad that they are a useful auxiliary ia the treatment of phthisis, whatever other power they may possess, nAS been established to my satisfaction. Testimony of Dr. Dickson, of Jersey. His Visit to Dr. Churchill. [Reported to the London Medical Circular.] In tho month of October last, while in Paris,I visited Dr. Churchill's Dispensary, and being satisfied from what I saw that there was something in his treatment of consumption, by tho use of hypophosphites, on my return to this place I put the treatment ia practice, and have found it so beneficial in tho majority of the cases so treated, that I am induced to persevere. I havo tried it in about thirty cases, in every stage of the disease, and in tho majority—say two- thirds—the improvement has been very marked. My experience has proved, that it is decid- edly beneficial in the earlier stages of the disease, although one very material effect of the medicines, viz.: their power of checking night sweats, makes them very useful in all stages. What convinced mo most in the cases I saw under Dr. Churchill's care, was the fact that tboso who presented themselves at the Dispensary were generally those of the lower classes of society, who camo there laboring under phthisis (as proved by auscultation and percussion) and who then returned to their daily avocations,bad ventilation,bad drainage, bad food (half tho timo, perhaps, nearly starved), aad obliged to work for that food—therefore, I reasoned, If these cases improve, there must bo something in the treatment. Since my return from Paris, I havo requested several medical friends to try tho treatment on their patients, and they have mentioned to mo that tho result was most extraordinary. THEY HAVE GIVEN THE TREATMENT A MUCH FAIRER TRIAL THAN DR. COTTON AND THE BROMPTON M. D.'s HAVE EVER DONE. Time alone can show how far tho improvement may be perma- nent. My experience, howover, satisfies mo, that ia tho hypophosphites we havo a.powerful agent, and that, on the score of humanity alone, they ought to have a fair aad impartial trial I may mention that the results of tho treatment on a near relative of mine, who has been for somo months under Dr. Churchill's care, is as satisfactory as it is gratifying. 144 APPENDIX. [EXTRACTS FR02V. MEDICAL JOURNALS, &c. " IlYrornuspniTES.—Whatever may be the estimate placed on Dr. Churchill's theory of the adaptation of this class of remedies to tho cure of Phthisis, yet all will be impressed with the importance of civing them a FAIR trial. The announcement of Mr. Winchester, in our advertising columns, will enable physicians to procure them, prepared strictly by Dr. ChurchilVs method, and thus test their valuo. Mr. Winchester is WORTHY OF ALL CONFIDENCE, and devotes himself enthusiastically to these preparations, in all their variety of combinations." —D. Meredith Reese, M. D , l.L. D., Ed. N. Y. Med. Gazette. ' There is no disease in tho long list that human nature is subject to, tho treatment of which has occupied the minds of physicians so constantly, and for so long a period, as that of pulmonary phthisis Time after timo tho discoveries of remedies havo been announced. Tho compounds of iron, sulphur, iodine, cod-liver oil, etc., have been arrayed before tho public, and had fair and persistent trials, and they all have failed to establish tlie virtues claimed for them, although wo admit that many of them are exceedingly useful in palliating some of the distressing symptoms of this disease. '' At this point wo find Dr J Francis Churchill, a physician well known to the medical profession, taking up tho study of tuberculosis in 1855, while engaged in the practice of medicine at Havana. * * * Dr. Churchill, in his first statement, gives very de- tailed statements of thirty-four cases, nine of which were thoroughly cured, eleven relieved, and fourteen appeared to receive no benefit. If theso relative numbers are to express what future practice is to bo ia tho caso of tho Hypophosphites, these compounds would certainly 113 said to possess cheat virtue. * * With theso facts before us, it cortainly be- comes tho medical profession to give the Hypophosphites a fair and persistent trial.''—Drs. S. M. Remiss and J. W. Benson, Eds. Louisville Medical News. ' The uso of that class of salts known as Hypophosphites offers the most direct and philo- sophical means of supplying th: phosphorus to the system. The small amount of oxygen in com- bination with this element ia the hypophosphorous acid which unites with tho alkaline car- bonates, the bases of those salts, is favorable to easy decomposition in tho economy. By the changes which result from further oxydation, nascent phosphorus and phosphorates arc liberated. The phosphorus thus set free is certainly in a condition most favorable to the fulfill- ment of its design and high office in the brain and nervous system. "—Boston Medical and Swgical Journal. " Whatever may be our conclusions with reference to the claims of Dr. Churchill for the Hypophosphites as sovereign remedies in tuberculosis, there can he no doubt as to the value of these salts AS remedial agents."—American Medical Monthly (N. Y.). " We now seo the rationale of the employment of the Hypophosphites of Limo and Soda recommended by Dr. Churchill, ia the treatment of consumption—they not only act as ab- borbexts, but repair or retard the waste of tissue."—H. V. Be Wees, M. D., New York (in the American Medical Monthly). " Tho recent recommendation, by Dr. Churchill, of the uso of tho IlYPOPnosriinrs in tho treatment of Phthisis, is now undergoing a general test by the medical profession. * * * From my own observation aad inquiry, patients using the hypophosphites have experienced marked relief from many of the annoying symptoms attendant upon Phthisis."—J Lawrence Smith, M. D., Professor of Chemistry ia tho University of Louisville. (From tho Louisville Medical Netvs.) "Thi3 mediciao is scientifically prepared, and reliable. Wc have used it in our own practice, in Ththisis Pulmonalis, and other forms of disease, with very satisfactory results. * * * Ia sixty -eight cases in which this remedy was given, thirty-seven wcro ia tho in- cipient, and twenty-three ia the second and advanced stages of consumption , tho remainder were beyond hope With the exception of tho latter cases, which were much benefited, all bit three, which aro sti'.l doubtful, recovered perfectly "—North American Medical Reporter. " On every side we soo our brethren tako hold of tho Hypophosphites, for the purpose of giving them a fair trial: and, as far as wo know, the results seem to be bntirely favorable confirming thoso already obtaiaod by Dr. Churchill. "-Drs. J. L. Kleenan and W. O'Meagher! Eds. N. Y. Med. Press T O : THE UNDERSIGNED, HAVING PERFECTED HIS ARRANGEMENTS FOR EXTENDING THE MANUFACTURE OF THE VARIOU.S HYPOPHOSPHITES, [AFTER THE ORIGINAL FORMULA OF DR. CHURCHILL] Is now prepared to supply the Medical Profession, and Druggists, with his chemically-purr. and reliable Preparations of these SALTS, in all quantities, and at the shortest notice. It must be obvious to every candid and thoughtful physician, that the importance of pure remedies, in tho treatment of disease, cannot be overrated, or too strongly insisted upon ; as, upon this point, absolutely depends their therapeutical value. The professional, as well as non-professional person, who reads Dr. Churohili/s Treatise and the accompanying documents, with ordinary care, will at once perceive how essential it is that the Hypophosphites should be perfectly free from excess of lime, carbonates,phosphates. <£c.,the presence of which, even in small quantities, renders them " EXTIRELY UNFIT FOR MEDICAL USE." In regard to my " Preparations," I need only refer to the uniform testimony of the Medical Profession in their favor, wherever they have been used. They are now considered THE STANDARD PREPARATIONS OF THE HYPOPHOSPHITES IN THE UNITED STATES. WINCHESTER'S GENUINE PREPARATIONS. Price List.—Terms Cash. HYPOPHOSPHITES OF IJME AND SODA......(combined)..... 7 oz. bottles, $1 00 " " ................do......... 16-oz. " 2 00 HYPOPHOSPHITE OF POTASSA......... 7-oz «' i 00 " MANGANESE............... 7-oz " 1 00 " QUININE................................. 7-oz. « ioo e&- Physicians and Druggists supplied by the dozen, or larger quantities, at the usual discount. PURE SOLUTIONS OF THE SEPARATE SALTS. For Physicians' Prescription Only. HYPOPHOSPHITE OF LIME................. 6-oz. ground stoppered bottles, $1 00 SODA................... 6-oz " "1 00 " POTASSA................ 6-oz. •• « J no " MANGANESE............ 6-oz. •• •< i 00 jgQT Prices to the Trade, invariably, by the dozen___................... g 00 DRY SALTS. HYPOPHOSPHITES OF MME SODA, AND POTASSA, each, per ounce, net.. $0 50 MArsGANr^SE........ (\ p,{\ QUININE, in >4'-oz. bottles'.'... .'.'.' 777777 7 '.'.'. 7 '.'. 7.7.'. 1 50 N. B—The use of Hypophosphite cf Iron, in Consumption and Chlorosis, is considered to be srvtrrACinVBirE.rerefore'prepare this salt-(See opinio"s of Dr c™- 4®=" Orders for my Preparations can be addressed to either of the Wholesale Dru<* Houses of New York, to my Wholesale Agents, or to J. WINCHESTER, At the Sole General Depot, 43 John street, N. Y. 'f 16 C 7 NATIONAL LIBRARY OF MEDICINE NLM D3EDbl7fl 1 8MB NLM032061781