to thyroid tabloids and to the isolated colloid matter. He reserves for subsequent publication the chemical composition; but states that it contains a considerable quantity of iodin in organic combination, and he has succeeded in splitting off from it a body apparently identical with that obtained by Bauman from the entire gland. He further says, "If this substance be really active, it would indicate that the colloid matter owes its activity to the presence in it of an organic compound of iodin." He has administered this substance to two cases of myxedema, which are to be published later. We find in these observations, on the active ingredient of thyroid gland, that the works of Notkin, Renaud, Bauman, and Hutchison are all very much in accord, showing, evidently, that we are on the eve of discovering the real active element; when this is done, it will probably be used in the place of the gland itself, and glycerin extracts of it.

It appears probable that in the largest proportion of these cases of myxedema in the adult, and especially so in the infantile form, the use of the gland at intervals will be necessary to insure health.

The gland is at present administered as a desiccated powder; as tablets, and tabloids; also a glycerin-extract; occasionally as cooked fresh glands; great care is necessary in selecting these glands, as a large number of them are found to be diseased. The sheep's thyroid is always used; when the glycerin-extract is employed, it is given hypodermically in about fifteen minims at a dose, every other day, or less often. To continue the effect, Dr. Murry, who instituted the treatment, gives one injection of twenty minims every two weeks. Care is to be observed in the administration of the thyroid, as death has been known to result from its use. Some surprise has been expressed at the small size of the dose that I used, and this might well be, when one constantly hears of physicians advising fifteen grains a day. It is a great deal better to begin with small doses, two or three times a week, even if you obtain the result desired more slowly, than to deluge the patient with it. The anemia which is present in some of the well-marked cases has not disappeared, even when all the other symptoms. have done so. It would be interesting to have a chemical and microscopic examination of the blood in these cases of persistent anemia. In the conditions in which thyroid gland has been used and with some benefit are psoriasis and obesity-the loss of weight in some cases of obesity is remarkable.

This paper has already exceeded its intended limits.

I can,

therefore, only name a few very recent papers and communications by Schlesinger, Ewald, and Starr.

DISCUSSION.

Dr. Shaw Dr. Brush has just written me a little note, stating that the little child I had in the Long Island College Hospital is now in the wards for nervous diseases at the Kings County Hospital.

Dr. Arthur C. Brush: That child when it came under my care last May had relapsed very markedly. It would sit on the floor, pay no attention to its surroundings, with mouth wide open and tongue protruding, with thick lips, keeping up a plaintive cry at times, paying no attention to its surroundings or even caring for food. We put the patient back on the thyroid and in a month's time he walked around the ward by taking hold of the chairs, and would say "Papa" and "Mama;" and then, to test the permanency of this remedy, we stopped it and the child again relapsed into the former condition. He was again placed on the drug and improved, and at the present time is improving on the drug. wanted to find out from this child how permanent this cure would be; whether these children would need to go on all their lifetime with this thyroid, or whether we might hope for something more permanent. But from the cases I have seen, it would seem that the children must go on taking the thyroid or relapse.

Another condition which Dr. Shaw did not mention, and that is sclerodema, which seems to me to belong to the same category of diseases as myxedema. I saw two cases at the Academy of Medicine last April, presented by Dr. Dercum, and about a month ago one came under my care at the Central Dispensary. She is a sister of the girl in the Kings County Hospital. The right arm was probably three inches larger in circumference than the left, the fingers short and stubby, the hand stiff and all the joints immovable, the skin rough and harsh. We placed the child on half-grain doses of thyroid three times a day, and that condition disappeared in a week. When the treatment was stopped it showed signs of returning. I have again commenced the treatment and I suppose with the same results.

A curious case came under my observation resembling Graves' disease, occurring in Dr. Parish's practice, showing some relation between oversecretion of the thyroid and exophthalmic goitre. A lady under his care was told to take one tablet of Parke, Davis' thyroid three times a day for obesity. She was delighted

with the result and she thought if one tablet was so good a larger number would be better and she might finish the bottle. She took forty or fifty grains to the dose. Within a few hours the pulse rose to 140, eyeballs protruded, the face became flushed and she suffered with vertigo, and since that time she has been a very fair picture (with the exception of the enlargement of the thyroid) of exophthalmic goiter.

In the other diseases of the nervous system, excepting syphilis and locomotor ataxia, I have had good results with thyroid, but in all other conditions I have had practically no results.

Dr. J. M. Winfield: I have been greatly interested in Dr. Shaw's paper, for myxedema is a disease which interests the dermatologist as well as the neurologist. The treatment of this affection by thyroid extract has opened a new field in cutaneous therapeutics. The dermatologists throughout the world have experimented with it in various skin diseases characterized by thickening and drying of the skin. (Pachydermatosis.)

Among the skin diseases which Dr. Shaw mentioned was psoriasis. This is a disease which dermatologists in all countries have tried to cure with thyroids. Bramwell, of London, and Tierbierg, of France, have submitted several reports regarding their experience with this remedy. They are not strongly impressed with its efficacy. I have experimented considerably with it in psoriasis. A few of the cases seemed at first to improve, but after a time relapses occurred. In others there never was any apparent benefit. This has been the experience of nearly all observers.

Dr. Brush is to be congratulated on the wonderful results obtained in his case of sclerodema. To cure a case of this disease, especially of the magnitude that his must have been, in one week, is truly wonderful. My experience of the use of thyroids in ichthyosis is limited to one case. Here it had a beneficial effect as long as the drug was continued, but when stopped the ichthyotic condition returned. I have been especially interested in the action of the desiccated thyroid in a case of nerve leprosy under my care. Two grains were first given daily and the dose was gradually increased until the patient was receiving twenty grains. This was the maximum amount The patient then became poisoned, The drug had a good effect on the trophic ulcerations and almost succeeded in healing them; after the patient had taken the thyroid for a month the ulcers began to fill in and improvement continued until I lost sight of the case. The pathology of myxedema and various skin diseases is somewhat similar. There is a quantity of

mucin thrown out, connective tissue is increased. This is the case in anesthetic leprosy; there is a quantity of mucin, as well as leprotic material, thrown out into the nerve, binding down its tissue, which is the cause of the anesthesia and the trophic ulcerations.

I personally wish to thank Dr. Shaw for bringing up the subject of thyroid therapeutics, for it certainly is one of great interest to all practitioners.

Dr. Shaw: What were the symptoms in the patient that became toxic, where the twenty grains were given?

Dr. Winfield: Diarrhea, vertigo, and vomiting. The first symptom was dizziness and rather rapid beating of the heart. The gastric disturbance followed later.

Dr. William Browning: This is certainly an important series of cases which Dr. Shaw has presented. One or two points I might speak of, though I have had no experience in just these cases with this remedy. One possible case of the toxic influence of the drug, I saw a paretic who had been receiving three grains three times a day, and the dose was increased to five grains three times a day. Directly after this increase of the dose, he had an attack of pseudohemiplegia, which seemed as though it might be due to that. came on so soon after the increase to five grains that I was inclined to believe it was due to the action of the thyroid. At any rate, the remedy did not prevent the attack.

It

One other possible point that somebody lately has called attentention to the relation which may or may not exist between cases of angio-neurotic edema and myxedema, apparently widely distinct affections. One case which Dr. Shaw related also suggests the possibility of such relationship.

Dr Shaw I might say, Mr. President, that the youngest sister of the girl that was here before you, is now a patient at the clinic of the Eye and Ear Hospital, for chorea, showing the neurotic element in the cases.

Dr. Jos. H. Hunt: In regard to the question of these toxic symptoms after the administration of the thyroid extract in large doses, I would like to ask those who have used it, if they have settled what produces the toxemia, whether it is the essential principle of the thyroid gland, the medicinal properties of it, or whether it might possibly be due, where the large doses are given, to a ptomain in the dried animal matter or dried meat so to speak. The diarrhea, that Dr. Winfield has spoken of, might possibly be due

to ptomain-poisoning. Personally I have had very little experience with it.

Dr. Henry N. Read: I have had some little experience in the use of the thyroid extract in the treatment of exophthalmic goiter, but none in the treatment of cretinism. I have treated three cases

of goiter "in extenso," so as to be able to give results as to the value of the thyroid extract. Two of these have recovered their health entirely, so far as I can determine. The third case has improved somewhat, but not to a marked degree, and is still under treatment. This third case was one of simple goiter with no exophthalmus whatever, and has existed for seven or eight years. The patient is now a young woman twenty-three years old, the trouble commencing when she was fifteen years old. She has been under the care of many different physicians, and finally came under my care in the spring of this year. She had, heretofore, obtained no relief whatever from the use of the thyroid extract, and very quickly exhibits the toxic symptoms of the drug after using it. She was under the care of Dr. Dessau some years ago, and I had some communication with him on this subject. The doses he gave then he had to prepare himself—it was before the time when the drug was sold in the market—and there was a good deal of guesswork as to how much the patient took. She was made very ill and uncomfortable by its use, and after a time she gave up the use of the drug, and drifted from Dr. Dessau's care to others. She is still under my observation. She can take now not more than three grains at a time and only once or twice daily. More than this causes violent heart disturbance, with dizziness and nausea. My first case was that of a young man, or rather lad, who was taken sick three years ago, when he was fourteen years old-he is now seventeen-and he has made a complete recovery, from what seemed a very bad case. He had very rapid enlargement of the thyroid gland, protrusion of the eyes to a marked degree, and cardiac disturbance in a most distressing manner. He had to give up his business, and nothing seemed to have any effect in checking the disease until I gave him the thyroid extract. He began by taking very small doses-it was about the time that the thyroid was first put up in tablet-form-not more than one or two grains daily. He improved so rapidly that I increased the quantity to three, and then to five grains three times daily. I continued this quantity for some time without him having any trouble from it, and he made an excellent recovery and is at present entirely well. My other case, that of a lady about twenty-eight