FIRWEIN

“Castanea, fresh leaves, 40 gr.; Passiflora, fresh plant, 40 gr.; Gelsemium, green tincture, 8 minims; Inula, represented by the camphoraceous stearoptene Helenin, 20 grs.; Iodized Lime, 8 grs.; Menthol, 1-4 grs.; Aromatic Syrup Yerba Santa, 60 minims.”

It is said to be:

“A new combination of well-tried remedies of especial value in pertussis and other spasmodic coughs. It is composed of astringent, antispasmodic, sedative and expectorant agents, that control the paroxysms, relieve the irritation, promote expectoration, and give tone to mucous membranes involved.”

Still more exaggerated claims are made for the individual constituents of Casta-Flora, partly by direct statement, partly by inference. For example:

“Castanea is almost a specific in whooping cough and other spasmodic coughs.“Passiflora is a narcotic, sedative and antispasmodic without habit-forming properties, nor does it lock up the secretions and upset digestion like opiates.“Inula (elecampane) has been employed as a cough remedy in England for centuries. Its action is similar to guaiacol and creosote. Its active principle, helenin, is destructive of tubercle bacilli in dilutions of 1 to 10,000.“Iodized Lime, Menthol, and Yerba Santa are too well known as expectorants and antiseptics to require more than passing mention.”

“Castanea is almost a specific in whooping cough and other spasmodic coughs.

“Passiflora is a narcotic, sedative and antispasmodic without habit-forming properties, nor does it lock up the secretions and upset digestion like opiates.

“Inula (elecampane) has been employed as a cough remedy in England for centuries. Its action is similar to guaiacol and creosote. Its active principle, helenin, is destructive of tubercle bacilli in dilutions of 1 to 10,000.

“Iodized Lime, Menthol, and Yerba Santa are too well known as expectorants and antiseptics to require more than passing mention.”

That Casta-Flora is a “new” combination may be admitted; it is improbable that exactly this combination of obsolete drugs was ever before selected for any purpose whatever, but the statement is misleading in that no new principle of therapeutics is involved. On the contrary, the combination is just what might be expected from haphazard choosing of discarded and nearly forgotten drugs. It seems incredible that a reputable firm of manufacturing pharmacists would make the positive statement that castanea isalmosta specific in whooping cough. Why not say it is a specific? It would be about as true. A specific or “almost specific” for this disease would rank among great medical discoveries; but castanea is merely a slightly astringent drug neither better nor worse than scores of other astringent drugs that have been tried, found valueless and discarded.

Hardly less surprising are the statements regarding passiflora. This herb has been on the market about three quarters of a century. Not only has it never established itself in scientific medicine, but it is not even mentioned in modern standard works on therapeutics.

Of all the statements made in the circular perhaps the most remarkable, in that it is so dangerously misleading, is that regarding helenin, the active principle of elecampane. The statement that this principle (helenin) is destructive of tubercle bacilli in dilutions of 1-10,000 can only mean that it is of extraordinary value in the treatment of tuberculosis; in fact, it is definitely stated that the action of elecampane is similar to that of guaiacol and creosote.

It is obvious that any drug which would destroy the tubercle bacilli in the human lungs without exerting a toxic action on the patient would be a great contribution to medicine. But although elecampane may have been used for centuries it has proved to have little, if any, merit, and even the National Standard Dispensatory, p. 848, says: “Elecampane was formerly employed as a tonic, stimulant, diuretic, diaphoretic, expectorant, and emmenagogue, but has now largely fallen into disuse.” One looks in vain in the standard textbookson therapeutics for a description of the uses of inula (or elecampane), and of its so-called “active principle,” helenin.

The circular to which reference has been made says, referring to the use of castanea and passiflora in the treatment of whooping cough:

“Gelsemium, when made from the fresh, green plant—as is Merrell’s—is an excellent adjuvant to the above drugs, and allays the nervous irritability so frequently present.”

H. C. Wood, Jr. (Pharmacology and Therapeutics, 1916, p. 160), says of gelsemium: “Gelsemium was originally employed as an arterial sedative and febrifuge in the malarial fevers of the South, and subsequently in sthenic fevers. It appears in some way to depress the bodily temperature, but it does not appear probable that any advantage to be derived from it will counterbalance the danger attending its employment in the large doses required. In asthma, spasmodic laryngitis, whooping cough, and nervous cough it has been recommended by Bartholow, but is little used.”

That is about as favorable a statement for the drug as is to be found in the textbooks, and it serves to illustrate how little new there is in this mixture of obsolete drugs that Merrell seeks to market as one possessing extraordinary therapeutic value.

Even though the ingredients, or certain of them, were singly useful in the treatment of those conditions for which Casta-Flora is recommended, no one could possibly foresee the effect in any given case of such a jumble of drugs, both active and inert, as is said to be represented in this preparation. The prescribing of such mixtures, the action of which cannot in any way be foreseen, is plain charlatanism.

In addition, the various drugs in Casta-Flora are present in such proportions that the dose of each of the several ingredients bears no relation to the commonly accepted dose.

Casta-Flora is not acceptable for New and Nonofficial Remedies.—(From The Journal A. M. A., Jan. 27, 1917.)

Firwein is a product of The Tilden Company, New Lebanon, N. Y. It is sold under the claim that when swallowed it has a “predilection” both for the bronchial mucosa and also for the genito-urinary organs. To quote:

“Expectorant, Sedative, Antispasmodic in the Treatment of Inflammations of the Bronchial and Genito-Urinary Mucosæ.”“Firwein being a bland, soothing balsam possesses a wide range of adaptability and increased potency because of its healing virtues and usefulness as an expectorant, sedative and antispasmodic in bronchitis, and inflammation and catarrh of nose, throat and lungs.”“Firwein has a special predilection for mucosæ, this being as marked in diseases of the genito-urinary system as it is in the respiratory organs. In inflammatory diseases of the genito-urinary organs, its bland, curative properties are exerted in a gratifying degree. In cystitis and uritis it is clearly indicated....”

“Expectorant, Sedative, Antispasmodic in the Treatment of Inflammations of the Bronchial and Genito-Urinary Mucosæ.”

“Firwein being a bland, soothing balsam possesses a wide range of adaptability and increased potency because of its healing virtues and usefulness as an expectorant, sedative and antispasmodic in bronchitis, and inflammation and catarrh of nose, throat and lungs.”

“Firwein has a special predilection for mucosæ, this being as marked in diseases of the genito-urinary system as it is in the respiratory organs. In inflammatory diseases of the genito-urinary organs, its bland, curative properties are exerted in a gratifying degree. In cystitis and uritis it is clearly indicated....”

Little information is given concerning the composition of Firwein. An old circular says:

“Firwein contains Phosphorus, Iodin and Bromin finely blended with a balsameous elixir made from the fir tree.”

From a more recent circular we quote:

“Firwein is prepared from the inside fresh green bark of the fir tree...”

The label on the product reads:

“Firwein is pleasantly and effectively blended with salts of iodin and bromin, held in solution with 20 per cent. alcohol.”

The therapeutic claims made for Firwein and the mystery enshrouding its composition make it obvious that the product is intended to appeal to those who are either thoughtless or ignorant. This is emphasized by the suggestion that Firwein be combined with (1) cod liver oil (under the claim that it will “promote the efficiency of the oil”), with (2) whisky for the treatment of bronchorrhea of the aged, and with (3) syrup of hypophosphites for the treatment of persistent bronchitis.

As the composition of Firwein is secret, the therapeutic claims unwarranted, and its use irrational, the Council declared it inadmissible to New and Nonofficial Remedies.—(From Journal A. M. A., Feb. 17, 1917.)

Firolyptol, another product of The Tilden Company, is, we are told, composed of eucalyptol 10 drops, cottonseed oil1⁄2ounce and Firwein enough to make 1 ounce. As the composition of Firwein is secret, it is evident that the composition of Firolyptol is also unknown, except to the manufacturers. “Firolyptol with Kreosote” is said to contain, in addition to whatever may be the component parts of Firolyptol, 10 minims of creosote to each ounce. According to an advertisement, Firolyptol with Kreosote is “antituberculous, antistrumous” and “contains all the desired features of cod liver oil and is readily assimilated.”

The advertisements of “Firolyptol Plain” and “Firolyptol with Kreosote” seem to have for their key-note the assertion that cottonseed oil is a particularly valuable nutriment and that when combined with constituents of Firolyptol and Firolyptol with Kreosote becomes particularly valuable to the tuberculous. To quote from an advertising circular:

“Now that the reconstructive properties of cottonseed oil are better appreciated by the profession, the advantages that follow the administration of a palatable emulsion of this strengthening and fattening food product are being demonstrated in hundreds of cases where formerly reliance would have been placed in cod liver oil.... A recent writer says that pure cottonseed oil is the greatest and purest vegetable oil known to chemistry, and will do much toward revolutionizing the treatment of theGREAT WHITE PLAGUE.... If the treatment of tuberculosis could resolve itself into the administration of a fatty substance in a readily assimilated form, there would be no need for any part ofFIROLYPTOLbut the Cottonseed Oil.... The toxic material constantly produced in the system by the germs of tuberculosis tend to expose it more and more to the ravages of the disease, and the physiologic functions of the body suffer a constant depression. To neutralize this germ activity with a consequent production of toxins it seems most logical to employ such agents as have demonstrated their suitability for such purposes, for which reason Eucalyptol and Kreosote with Firwein are incorporated inFIROLYPTOL.”

The assertion that cottonseed oil is an especially valuable form of fat is without warrant, but even if it were true the fat is available in cheap and palatable forms in numerous other cottonseed oil products. It is unnecessary to discuss the problematic value of creosote in the treatment of tuberculosis or the value of eucalyptol (now generally abandoned), or even of the secret mixture Firwein. Food and fresh air, not drugs, constitute the fundamentals of the treatment of tuberculosis, and it is both irrational and detrimental to the interests of the tuberculous to administer various potent agents in fixed and unknown amounts with such simple articles of food as cottonseed oil. Neither of these products is acceptable for New and Nonofficial Remedies.

Editorial Note.—Firwein110has been advertised to physicians for twenty-five or thirty years and it is a sad commentary on the intelligence of our profession that a preparation sold under such obviously false and misleading, not to say silly, claims, should still be in existence. Firwein is claimed to “prevent waste of tissue” in tuberculosis. If it had this power, it would have found its place long ago among the few great agents in drug therapy. As a matter of fact, Firwein has gained virtually no recognition outside of the “literature” of the Tilden concern. The claims made for Firwein are a peculiar mixture of studied candor—when the truth is not likely to hurt its sale—and inane vaporing—when the facts would not redound to its credit. The Tilden Company declares that “Firwein stands without a peer in its class.” But the company adds 10 drops of eucalyptol and some cottonseed oil to this peerless product and an improvement is born—“Firolyptol”! Then, to perfect the already perfectly perfected, 10 drops of creosote are added to “Firolyptol” and the profession is offered “Firolyptol with Kreosote”! In just what verbal pyrotechnics the Tilden Company might indulge, should it decide to add ten drops of something else to “Firolyptol with Kreosote,” one shudders to contemplate.

If we are accused of exhibiting undue levity in discussing a therapeutic problem, we can only answer that it is impossible to consider seriously the Charlie Chaplins of the nostrum world.—(From The Journal A. M. A., Feb. 17, 1917.)

In accordance with the usages of the Council, the report which appears below along with the reports of the clinical investigation by Drs. Cole and Keidel upon which the recommendations of the referee were based were sent to the manufacturer for comment. The reply of the manufacturer contained no evidence which justified the Council in modifying the action already taken. Publication of the report was therefore authorized.

W. A. Puckner, Secretary.

Biniodol was submitted to the Council by the manufacturer, Charles C. Yarbrough, Memphis, Tenn. The manufacturer claims the product is a solution of 1 per cent. of red mercuric iodid and 2.75 per cent. of guaiacol in bland vegetable oil. It is marketed with the implication that it is new and superior to other oil solutions of mercuric iodid. For instance:

“... it is a straight solution of this mercurial compound, as no alkaline iodide or other chemical is used to bring about the solution.” “... It is probably the first and only one-percent oil solution of straight mercury biniodide made in America....”[The manufacturer, in a letter addressed to the secretary of the Council, explains: “By straight solution, I mean that the solution of the red mercuric iodid is effected without the aid of any alkaline iodid or other chemicals.... Biniodol was first offered early in 1912...”]“Biniodol is, therefore, superior and much to be preferred to other mercurials used for like purposes. It is highly active therapeutically, producing the desired effects, usually without the inevitable disadvantages of other mercurials. It rarely causes salivation, diarrhea, or other symptoms of mercurial intolerance, even when pushed to full therapeutic effect and when given for a considerable period of time. Nor does it produce anemia.”

[The manufacturer, in a letter addressed to the secretary of the Council, explains: “By straight solution, I mean that the solution of the red mercuric iodid is effected without the aid of any alkaline iodid or other chemicals.... Biniodol was first offered early in 1912...”]

“Biniodol is, therefore, superior and much to be preferred to other mercurials used for like purposes. It is highly active therapeutically, producing the desired effects, usually without the inevitable disadvantages of other mercurials. It rarely causes salivation, diarrhea, or other symptoms of mercurial intolerance, even when pushed to full therapeutic effect and when given for a considerable period of time. Nor does it produce anemia.”

The Chemical Laboratory of the American Medical Association found that Biniodol contained 1 per cent. of mercuric iodid and 2.5 per cent. of guaiacol; hence the composition is essentially as claimed. It is not true, however, that Biniodol is the “first and only one-percent solution of straight mercury biniodide made in America.” As shown inThe JournalA. M. A., Dec. 9, 1914, p. 2247, formulas by Lemaire and Dunning for making a “straight” solution of mercuric iodid were published in this country in 1909 and 1910, respectively. Moreover, a 1 per cent. solution of mercuric iodid in oil is on the market and is described in New and Nonofficial Remedies.

To determine whether or not Biniodol is “superior and much to be preferred to other mercurials used for like purposes,” the Council secured the cooperation of the Department of Dermatology and Syphilology of the Western Reserve University cooperating with the Cleveland City Hospital, and of the Johns Hopkins Hospital. Each received three samples, labeled respectively, 1, 2 and 3: 1 contained Biniodol; 2, a 1 per cent. solution of mercuric iodid in oil; 3, a solution made up according to the formula of Biniodol, namely, 1 per cent. of mercuric iodid and 2.5 per cent. of guaiacol in oil. All the solutions were sterile. The investigators were not informed which preparation was designated by the respective numbers, but they were asked to use the preparations when intramuscular injections of a 1 per cent. oily solution of mercuric iodid were indicated, and to note what differences, if any, were observed following the use of the different solutions regarding pain, discomfort, induration and any other evidences of effects of the medicaments.

The Cleveland investigator reports that the patients were more or less confused in their replies to inquiries and gave rather indefinite and conflicting answers. After carefully tabulating the replies, however, the following summary resulted:

1 was worse than 2 or 3 in 6 cases.2 was worse than 1 or 3 in 5 cases.3 was worse than 2 or 1 in 1 case.

The report from Johns Hopkins records a series of 117 injections followed by the estimated reactions recorded below:

1. Severe, 13; mild, 14; none, 4; unrecorded, 8 = 392. Severe, 5; mild, 15; none, 16; unrecorded, 5 = 413. Severe, 7; mild, 25; none, 3; unrecorded, 2 = 37

That is, when recorded in percentages:

1. (Biniodol) severe, 33.3; mild, 35.9; none, 10.3; unrecorded, 20.5.2. (Without guaiacol) severe, 12.2; mild, 36.8; none, 39.0; unrecorded, 12.2.3. (With guaiacol) severe, 18.9; mild, 67.5; none, 8.1; unrecorded, 5.5.

The manufacturer of Biniodol supplied the names of several physicians who have used that preparation in their practice. Correspondence with these elicited the following statements:

One had used Biniodol in forty-eight cases and states that “only a few patients complain of pain at all and then only of a general soreness in the muscle.” This physician reports a limited experience with the use of another manufacturer’s “mercury biniodide oil solution” (apparently six cases), but severe pain following the injections made it necessary to abandon that preparation.

Another of these physicians named by the manufacturer, without reference to any series of cases, reports that “Biniodol is superior to any [oily solution of mercury biniodid] that I have tried.”

A third physician has “used it [Biniodol] a few times” and is “convinced that it has no special action or virtue” over “any red mercuric iodide in oil.”

This evidence, in its most favorable estimate, shows Biniodol to be a good 1 per cent. solution of mercuric iodid in oil, but fails to justify attributing to the preparation any unique characteristics. The preparations made in the laboratory were as satisfactory, or better than the Biniodol, and the presence or absence of the guaiacol was of no consequence.

Biniodol conflicts with Rule 6, since claims of superior therapeutic efficiency made for it are not established; and with Rules 8 and 10, since it is an unessential modification of an established nonproprietary article marketed under a proprietary name.

In view of the foregoing, the referee recommends that Biniodol be not accepted for New and Nonofficial Remedies, and that this report, including the clinical investigations of Drs. Cole and Keidel, be authorized for publication.

At the request of Prof. Torald Sollmann of the Council on Pharmacy and Chemistry of the American Medical Association, we made a comparative study of several oily preparations of red mercuric iodid for intramuscular injections in syphilis.

The information, concerning the preparations submitted to the investigators, was as follows:

“It is desired to ascertain whether there is any difference between three preparations, each containing 1 per cent. of mercuric iodid, as to pain, discomfort, induration, etc. The preparations will be labeled “1,” “2” and “3.” They will be sterile.

“One of these preparations will be a plain solution in oil; another will contain, in addition, 2.5 per cent. of guaiacol; the third will be a proprietary preparation containing the guaiacol.

“It is also desirable to know how the oily solution compares with the plain watery solution; but this is of secondary importance.”

The preparations all had the same appearance. The patients were taken indiscriminately, and we attempted to keep them on the injections as long as possible, in order to compare symptoms. Owing, however, to discharge from hospital, symptoms of mercury intoxication, etc., we were unable in all cases to give a thorough trial with each preparation.

In all, eleven patients were treated and seventy-one injections given—by which time our experimental supply was exhausted.

In each case the drug was given intramuscularly in the buttocks and the patients carefully observed for subjective symptoms of pain and for objective symptoms of swelling, induration, abscess formation, etc. The details are given in Table 1.

As will be noted, in several of the cases the patients were more or less confused and gave rather indefinite and conflicting answers. In attempting to compare the results from the different drugs, by careful tabulation one finds that symptoms were more marked with the respective sample as follows:

Preparation 1 was worse than Preparation 2 or 3 in six cases.Preparation 2 was worse than Preparation 1 in two cases.Preparation 2 was worse than Preparation 3 in five cases.Preparation 3 was worse than Preparations 2 or 1 in one case.

TABLE 1.—DETAILS OF INVESTIGATION BY DR. COLE*

CaseAgeSex†DatePrepara-tionDose,GrainSymptomsInduration—PainObjective125♂M6/11/1621⁄5NoneStill painful6/12/1611⁄4NoneNone6/13/1621⁄5NoneQuite painful6/14/1621⁄4Hurt for some timeVery tender6/16/1621⁄5Hurt for some timeVery tender6/17/1631⁄5Not so painfulLess tender than with Preparation 2. Can sit on area; as needle prick is only place that it hurts6/18/1631⁄5Not so painfulDiscontinued(salivation)6/22/1621⁄4Hurt, but not so longSlight induration and slight tenderness6/24/1621⁄4Hurt, but not so longPain “dead stinging” lasts 1 hour6/25/1611⁄4Not so badAbout the same232♂M6/24/1621⁄4Some painNo induration6/25/1611⁄4More painSlight induration3..♂M6/12/1611⁄5No symptomsPainful6/13/1621⁄4No symptomsPainful6/14/1621⁄4Says the last two have hurt the morePainful6/16/16Arseno-benzol6/17/1631⁄5More pain than previouslySmall painful area6/17/1631⁄56/18/1631⁄5Not so much pain: in fact, patient says he is over it in a very short while; complained of last oneSome induration at site of injections6/19/1631⁄56/20/1631⁄46/21/1631⁄46/22/1621⁄4Some painConsiderable tenderness now after so many injections6/24/1621⁄4Not so much as previously6/25/1611⁄4436♂M6/22/1621⁄4No painNo tenderness6/24/1621⁄4Some painSome tenderness6/25/1611⁄4Could not sleep at nightSome tenderness; slight induration532♂M6/20/16320 minimsSome painNo induration6/21/16325 minimsSome pain6/23/1621⁄4Worse painNo induration6/24/1621⁄4Worse pain6/25/1611⁄4Worse than anySlight tenderness620♂M6/ 8/1611⁄6Very little6/10/1611⁄5Very little6/13/1611⁄4Very little6/14/1621⁄4Bothered more than others6/17/1621⁄5Quite a little painStill some soreness6/18/1621⁄5Quite a little painStill some soreness6/19/1631⁄4Considerably less pain than with Preparation 2Very little tenderness6/20/1631⁄46/21/1631⁄4730♂M6/12/1611⁄5Little painNone6/13/1621⁄4No pain6/14/1621⁄5Some pain6/16/16Arseno-benzol6/17/1631⁄5Not so muchNo tenderness6/18/1631⁄5Not so muchNo tenderness6/19/1631⁄5Very little painOnly slight amount of induration6/20/1631⁄46/21/1631⁄46/22/1621⁄4Some painSome little induration6/24/1621⁄4Considerable painSome induration6/25/1611⁄4“Fine”Slight induration828♂MM6/13/1621⁄5Little painLittle pain afterward6/15/1621⁄5Little painLittle pain afterward928♀M6/17/1621⁄5Some complaint of pain. Fairly severeVery little induration6/18/1621⁄56/19/1631⁄5Some pain; says these have hurt very much less than othersVery slight induration6/20/1631⁄46/21/1631⁄41037♂M6/12/1611⁄5No symptomsNone6/13/1611⁄4No symptomsNone6/14/1611⁄5No symptomsNone6/15/1631⁄5No symptomsNone6/16/16Arseno-benzol6/17/1631⁄5“Much less pain than biniodid or grey oil”None6/18/1631⁄5No complaintNone6/19/1631⁄5Says he is over it in one hourSome induration at site of injection6/20/1631⁄46/21/1631⁄41130♀M6/11/16120 minimsConsiderable; not so muchConsiderable pain and tenderness on palpation over area6/12/16220 minims6/13/16125 minimsNot much painIndurated area at pt. of each. Painful6/14/16125 minimsNot much painSlight induration

* The diagnosis in Case 5 was primary syphilis, and in the other cases, secondary syphilis.† In this column,♂Mindicates male, and♀Ffemale. In no case did Wassermann become negative.

* The diagnosis in Case 5 was primary syphilis, and in the other cases, secondary syphilis.

† In this column,♂Mindicates male, and♀Ffemale. In no case did Wassermann become negative.

The criticism may be raised that the number of cases and of injections is too small to permit the drawing of any just conclusions. Even should we grant it, the statistics certainly do not prove any marked superiority of any one of the preparations over the others. We wish to thank Dr. Sollmann for advising and directing us in this work, and Drs. Bailey, Bernstein, Markus and Reycraft for assistance in carrying it out.

Twenty cases were chosen at random from the syphilitic patients attending the clinic. They were given intramuscular injections of the three solutions, in amounts varying from 1 to 2 c.c., at intervals (in most instances) of two days. The injections were invariably made into the gluteal muscles, at depths of from 2 to 21⁄2inches, and ordinary care exercised to preserve asepsis. After injection the patient was allowed to depart, and the result was recorded at the succeeding visit. The result was determined from the patient’s statement and our examination. Some patients received injections of only one solution; some were treated with first one and later with another, and one patient received all three at different times. The solutions were never mixed for a single injection, of course.

TABLE 2.—REACTIONS IN TWENTY CASES REPORTED BY DR. KEIDEL

PreparationReactionsNumber ofInjectionsSevereMildNoneUndetermined11314483925151654137253237——117

The solutions are understood to contain a 1 per cent. solution of red mercuric iodid in oil, two of them containing in addition 2.5 per cent. of guaiacol, one of these being a proprietary preparation. The solutions are designated as Preparations 1, 2 and 3, respectively, corresponding to the numbers on the labels of the bottles in which they were originally received. The local reactions are recorded as “severe” (S), “mild” (M), “none” (O) and “Undetermined” (U). By “severe” is meant very severe pain lasting for from several hours to several days; by “mild” is meant slight pain or numbness for several hours, or less than an hour; “none” indicates that there was no local reaction, and “undetermined,” that the patient has failed to return after the last injection.

In Table 3 all the details of the investigation are recorded. Under “Local Reaction,” the letters represent the type of reaction after each injection, in the order in which they were given; when two solutions were used in the same case, the letters represent the reactions following the solution opposite which they stand. In the fifth column the plus and minus symbols indicate the Wassermann reaction; plus indicates a completely positive, and minus a completely negative reaction. When there is only one sign, it refers to the reaction at the end of treatment; when there are two, to the reaction before and after. The seventh column shows the clinical result at the end of treatment; when no note is made, it means that there was no change noted. In the eighth column are noted any objective results observed at the time of examinations of the patients.

The injections were made and the result charted by Dr. E. L. Zimmermann, of my staff, under my directions and supervision.—(Abstracted in The Journal A. M. A., Feb. 24, 1917.)

TABLE 3.—DETAILS OF INVESTIGATION BY DR. KEIDEL

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