reme

fer. All that we know to-day about the pathology of tuberculosis, points conclusively to the fact that any arrest of the disease is accomplished entirely through the activity and competency of bodily forces. To speak of a "cure" for tuberculosis is therefore anomalous and liable, as in the present instance, to perpetuate erroneous ideas in the minds of the afflicted concerning "consumption dies." It is entirely probable that a treatment or some special agency will some day be discovered that will confer on the human body specific power of arresting and overcoming a tuberculous infection. But even then the cooperation of open air, good food and hygienic living will be just as essential, and so we get right back again to fundamental principles. As a matter of fact, there are a goodly number of remedies that already have been found more or less effective in connection with outdoor living and proper feeding in arresting tuberculosis. But they in no sense are "cures" for consumption, and no intelligent physician considers them as such.

It is to be hoped that the distinguished physicians in charge, whose names at once assure proper handling of the matter, will at an early date make an announcement that will coincide with established facts, and thus go far toward correcting mistaken ideas on the medicinal "cure" of tuberculosis. Too much time, effort and money have been expended in proving the essential place of sanitation, ventilation and hygiene in the arrest and prevention of tuberculosis, and the results have been too conclusive, to have these agencies jeopardized in the slightest by false ideas as to the part played, or liable to be played, by any specific remedy. The principal benefit likely to result, in our opinion, from this prize proposition, comes from the state

, 1910

, Vol. 1,

ment that pending disposition of the prize, the income will be used to investigate remedies that come to the attention of the

trustees or members of the advisory board. A vast amount of good can indeed be done by exposing the fake "cures," and giving to the public correct information concerning the treatment of tuberculosis.

The scientific study of the drunkard is the only way of ending the present deplorable differences of opinion. There is an increasing body of thinkers who are advocating segregation of these sick people so that protection can be afforded society and the sufferers. Cure is attainable in only a small percentage by present methods of tiding over a debauch. Something must be found to take the place of alcohol, and means must be discovered to so improve the nervous system that there will never arise that irresistible demand for narcosis. We strongly commend the present plan of confining the chronic drunkard under medical care takers. There are many suggestions worthy of trial-an increase of the sugar in the diet is said to furnish energy to relieve fatigue. It has proved beneficial with soldiers in campaign and with laborers, and it has been seriously advocated in the craving for alcohol. Surely it is worth investigating. There is such a demand for the exclusion of intoxicated men from the highways, particularly teamsters and chauffeurs, that law makers cannot ignore it. much longer. The joy-rider or drunken teamster is causing so many deaths, that it is not at all unlikely that arrests for habitual drunkenness in any calling will result in confinement until cured, but if relapses occur, then the safety of society demands. confinement for life. The time has long gone by, when the drunkard is considered. an enemy to himself alone.

ORIGINAL ARTICLES.

UNTOWARD EFFECTS OF THYROID MEDICATION AND HOW TO FOREGO THEM.1

BY

HEINRICH STERN, M. D.,
New York City.

A decade or so ago, preparations of the thyroid gland were much in demand; within the last few years the gross of physicians, at least in this country, have abandoned thyroid medication to a great extent. To what causes may this change be assigned? Are the preparations of the thyroid gland of so little value in the treatment of disease? Or are they so expensive that the practitioner had to forego their use? There are mainly two reasons which account for the relative abandonment of thyroid therapy. These are (1) the supposed or actual impurity of the thyroid preparations on the market; and (2) the untoward effects which thyroid administration has called forth in a great number of patients.

On this occasion I do not wish to enter into a discussion concerning the purity of the commercial thyroid products, neither do I wish to dwell at length on the chemical composition of thyroid extract and other preparations of the gland, nor upon the physiological behavior when these are exhibited in the healthy and diseased human organism. I shall briefly discuss a few points connected with the purely clinical side of thyroid administration.

The first and most thorough setback which thyroid therapy has received was undoubtedly brought about by the indiscriminate use of the thyroid preparations

in the treatment of obesity, and by the subsequent widespread fad of self treatment with the products of this gland to effect rapid reduction of body weight. In the wake of the indiscriminate use of thyroid by physicians, especially the tablets of thyroid extract, and of self treatment by patients with this preparation, there often occurred cases of digestive disturbance in varying degree, extreme nervousness, jactitation, general depression and other more or less severe manifestations of intoxication. Small wonder therefore, that the profession to be on the safe side abandoned thyroid therapy in a great measure.

Aberrant effects of thyroid medication, apart from an eventual impurity of the preparation employed, may be due (a) to the dose in which the product is administered; (b) to the constitutional characteristics of the patient. The first eventuality is a very important factor in the production of untoward phenomena. Not infrequently the physician advised a patient to take from three to four grammes (45 to 60 grains) of thyroid extract during the day, and often a patient under self treatment ingested twice or three times that amount. I remember that one patient, an actress of great embonpoint, took more than six thousand tablets of five grains each of a well known brand during the period of eight or nine months. But, strange to say, this lady seemed to be none the worse for her experience, and her weight in spite of dieting and the thyroid ingestion had not decreased more than from twelve to fourteen pounds. The more we study the action of a drug the better we will know to what cases it is particularly adapted, and in what amounts it ought to be administered. True enough, good results, especially in obesity, will often be attained by massive doses of thyroid

12

Complete Series, Vol. XVI.

extract, but the rapid reduction invariably ensues at the expense of body albumin, general resistance and vitality. A rapid disintegration of body albumin is, as a rule, accompanied by a chain of more or less pathological phenomena. Aside from the various untoward symptoms recounted heretofore, there are three concomitants of this pathological occurrence, viz., irregular heart action, glycosuria and albuminuria. If the dose of the thyroid extract be small enough, none of these manifestations may occur. As a matter of fact, however, body reduction by means of thyroid extract medication will not take place without giving rise at some time or other to a brief or protracted period of arrhythmia, or glucose or albumin excretion. Thyroid extract in doses large enough to effect body reduction is never a safe agent. While the thyroid in small amounts may not be a poison for the body albumin, large doses of the preparation undoubtedly exert toxic effects pre-eminently on the protoplasmatic constituents of the organism.

Different individuals are differently affected by the thyroid preparations. In a certain class of patients the ingestion of thyroid extract is rapidly followed by loss of body-weight and general improvement; in another class, there ensues loss of body weight with concomitant depression and toxic symptoms, and in a third class there occurs no, or very little loss of body weight. and no, or but very vague toxic phenomena. Individuals of the first class, those so favorably influenced by thyroid therapy, exhibit illy-pronounced myxedematous manifestations as inelasticity and doughiness of skin and subcutaneous tissues, periodical falling out of hair, markedly small thyroid gland, etc. in probably every in

stance.

New Series, Vol. V., No. 1.

Although many individuals bear well the administration of thyroid preparations, they cannot always be sought out before treatment is started. It is, therefore, more prudent to prescribe very small doses. of the drug in every instance when its administration is instituted.

Heretofore, thyroid therapy has found but limited employment. For a number of years its use has been practically confined to the treatment of obesity, myxedema, cretinism and related conditions. However, thyroid preparations have an active beneficial effect upon a variety of other pathological affections and states, such as certain forms of rachitis, infantile marasmus, migraine, epilepsy, eclampsia, certain types of chronic rheumatism and gout, continued high blood pressure, optic atrophy resulting from hypertrophy of the pituitary body, hemophilia, high fever, pruritus, psoriasis, etc.

Preparations of thyroid would find much. more frequent employment in the hands. of the general practitioner if he knew in what specific instances he could use them, and if he were assured that their depressing and toxic effects could be materially reduced.

The physician must also understand that the massive doses of the thyroid preparations originally recommended are only indicated in certain acute affections, and for but very brief periods at a time in the course of chronic pathological states. For the successful coping with nearly every phase of the chronic conditions in which there exists thyroid insufficiency, the employment of small doses will do effective work in the preponderating number of in

stances.

Excepting the small doses, do we possess any other means to protect the organism

, 1910

, Vol. V.,

About fifteen years ago I first observed that arsenic exerts a specific influence upon the activity of thyroid. Patients who took an arsenical and thyroid preparation at the same time never complained of untoward symptoms, while those who were treated with thyroid preparations alone occasionally exhibited such symptoms as I have mentioned. So pronounced was the modifying power of arsenic that in the course of time I never prescribed thyroid preparations without adding arsenic in some form. My observations have been confirmed by those of Bédart and Marbille (Compt. rend. de la Société biolog. Vol. 50, p. 566), who did not find palpitation, tremor, etc., following the administration of thyroid if Fowler's solution was given simultaneously.

In a communication of Gautier (sur l'existence normale d'arsénic chez les animaux et sa localisation dans certains organs, Compt. rend. Vol. 129, p. 929, etc.), which only came to my attention a short time ago, I again find a certain confirmation of my clinical experience. It is a fact that arsenic and iodine (iodine of the thyroid) are frequently encountered associated together in nature. Gautier found arsenic in the fresh thyroid gland of the dog, the hog (0.67 mg. per kilogram), the wether (0.5 mg.) and in man (7.9 mg.), and he is of the opinion that the arsenic is contained in the nuclein. Again, the beneficial influence of arsenic in Graves' disease points to its connection with the thyroid gland. If we now consider that the thyroid of man contains 7.9 mg. arsenic while that of the castrated ram exhibits but 0.5 mg. per

preparations on the market, which are derived from sheep, must be deficient in that element, the presence of which in larger amounts not only enhances the efficiency of the thyroid but also exerts a controlling. influence upon its total activity. In other words, the human thyroid contains about sixteen times the amount of arsenic than does that of the sheep which we employ for medication. It stands therefore to reason that the addition of a certain amount of arsenic to the thyroid preparation appears to be essential from the physiological as well as the clinical viewpoint.

Dimethyl arsenic acid (cacodylic acid) stimulates nutrition and possesses all the beneficial properties of arsenic without giving rise to its toxic effects. Instead of arsenious acid I have used for some time the dimethyl arsenic acid as a modifier of thyroid action.

As for the treatment of chronic conditions thyroid medication has to be continued for protracted periods, and as in nearly every one of the pertaining instances the heart's action leaves a good deal to be desired, I generally add one of the cardiac stimulants to the thyroid-arsenic combination. My studies of adonidin, a glucoside of adonis vernalis,1 convinced me that it is the safest and best of all the general heart tonics. In rapidity of action adonidin surpasses by far other heart remedies, such as digitalis, digitalin, digitoxin, caffeine, sparteine sulphate, strophanthus, convallarià majalis and convallamarin. In certainty of action it surpasses by far caffeine, sparteine sulphate, convallamarin, strophanthus and digitalis or its glucosides.

'Heinrich Stern-Adonidin, Physiologic and Medicinal Properties. An essay to which was awarded the first prize in the literary contest conducted by Merck's Archives. Merck's Archives, April and May, 1900.

In permanency of action, although it does. not call forth any cumulative effects, adonidin surpasses nitroglycerin, caffeine, convallamarin, sparteine sulphate, digitalis, digitalin and digitoxin. Of late, Huchard (Jour. de Médicine de Paris, Sept. 18, 1909), seven and a half years after I first published the formula of the arsenic acid-thyroidadonidin combination-concluded that thyroid extract should be combined with caffeine and sparteine sulphate in order to forego deleterious after effects.

This is a partial acknowledgment of my work along these lines, but I maintain that neither caffeine nor sparteine sulphate are drugs which, in point of efficacy can be compared with adonidin. They possess, however, the advantage of being much cheaper than the adonidin.

The thyroid combination which I prescribe at the present day is as follows:

Sodium cacodylate, 0.5 milligram= 1-200 gr.; adonidin, 2 milligrams=1-30 gr.; thyroid gland, dry powder, 5 centigrams=1 gr.; M. p. compressed tablet No.

I.

Fresh adonidin cannot always be obtained, its price is almost prohibitive. Caffeine may be substituted for it in doses of one centigram (% gr.). However, it must be remembered that caffeine is a substitute only, and whenever adonidin can be procured, and the patient is able to pay for it, it should be given decided preference.

In conclusion I venture to say that thyroid therapy will receive a new stimulus. as soon as the medical profession appreciates the fact that the addition to the thyroid of proper amounts of arsenic and a cardiac remedy will render the medication more efficient and deprive it of all or nearly all its deleterious effects. 250 W. 73rd St., N. Y.

A METHOD FOR THE INSTRUCTION OF THE PUBLIC ALONG MEDICAL LINES.

BY

H. SHERIDAN BAKETEL, A. M., M. D.,
New York.

"Tis education forms the common mind;
Just as the twig is bent the tree's inclined."
-Pope.

Education spells success to the young man of today. It is the watchword of the rising generation. Man builds his life structure upon an educational foundation, and as he is deficient in the fundamentals, in direct ratio he is likely to fail in accomplishing what his ambition desires.

In every walk of life men recognize the supreme value accruing from proper instruction. The American artisan of 1910 is a better and more capable mechanic than the artisan of 1810, for he has a better

knowledge of general affairs. The professional man of today is more truly a member of a learned profession than his predecessor of a century ago, because he has a more comprehensive idea of those branches which constitute a liberal education.

In the profession of medicine, marked improvement can be noted on every hand. There are now 141 medical schools in this country, some very high grade, some good and some poor, but the law of the survival of the fittest is rapidly eliminating the poor schools, and the good institutions are becoming better.

Many medical colleges demand from one to four years of academic college work as an entrance requirement. The list is constantly growing larger, and in twenty years the great majority of medical graduates will hold academic as well as medical degrees. Thus the dignity of the profession