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we were dealing with a disturbance of the thyroid gland, causing a diminished secretion, with a nor- mal mentality — a condition Online Cialis Canada of hypothyroidistn. We had to decide whether this extensive eczematous condition was due to deficient thyroid secretion or to other causes. If in spite of careful dietetic and local treatment for three years, an aggravated and more extensive process was produced, having a negative Wassermann and von Pirquet, we were justified Online Cialis Canada in assuming that the hypothyroidism was wholly responsible for the eczema, the same as it is responsible for the other cretinoid Online Cialis Canada manifestation. Can disturbances of the thyroid prodtice eczema? In considering the pathology of the skin in hypo- thyroidism, we find the skin undergoes a degenera- tion with a mucoid exudation into the subcellular tissue ; the epithelium of the sebaceous glands be- comes swollen and occludes the lumen, causing an- hidrosis and favoring dermatosis and eczemas. Cal- cott, Weill, and Fox report cases of eczema, Online Cialis Canada psoriasis, and ichthyosis due to diminished thyroid secretion. Winfield reports a case of skin manifestation in a child two and one half weeks old, and on autopsy the thyroid was found wanting. Bas- singer found that scaly like lesions of the skin de- velop in cretin rabbits. The hormone, or active prin- ciple, of the thyroid secretion, is supplied to the blood, as an iodized albuminoid, known as iodothy- rin. This iodothyrin must be in normal quantities to produce proper activation of the metabolizing functions upon fats and proteins, but if this hor- mone be diminished, as we have in this patient, the metabolism of fats and proteins is lessened and tends to produce intermediate products, a gain in weight, and a slowing of all functions. Sajous states that a perfect secretion of the thyroid is necessary for, i, proper relationship of the amount of fat to the rest of the body; 2, proper nitrogenous metabolism of the body ; 3, proper health and functions of the skin and its ap- pendages, hair, nails, etc. Hence, deficient secretion is apt to produce disturbances of skin functions and to interfere with the metabolism of proteins and fats. The skin being the largest fat organ in the body, therefore bears the brunt of the manifes- tations occurring in deficient thyroid secretion. It must therefore be Online Cialis Canada conceivable that changes in the hormone producing organs, resulting in disorders of general nutrition as above mentioned, may influ- ence the evolution of such skin manifestations as dermatoses and eczemas. In considering the treatment, we must bear Online Cialis Canada in mind that a child with deficient thvroid secretion 452 MILLER: Online Cialis Canada DONE GRAFT. [New Yoik Medical Jouinal. Online Cialis Canada lias lessened metabolic powers ; Magnus Levy, Uu P.ois, and Talbout, who have experimented with metabolism of cretins, found it to be very much less than normal. Talbout found that the meta- bolism of a cretin three and one half years of age was about equal to a normal child eight months old. This means that we must give less food to these children at the beginning of treatment and increase the food with the improvement. Fairly large doses of thyroid should be admin- istered at first, in order to remove results which have been produced by privation of thyroid secre- tion. Later, smaller doses are given to Online Cialis Canada maintain a normal equilibrium and prevent a recurrence. Fol- lowing improvement, the dose of thyroid which at first was sufficient later becomes an overdose, in- creasing the oxygenizing process, and the patient begins to consume his own fat. Thyroid, therefore, should only be given when definitely indicated. In conclusion, I may add that Online Cialis Canada if we regard the lesions of the skin as merely a symptom rather than a dis- ease, greater progress will be made. In every ob- stinate skin manifestation, a thorough physical and chemical examination of secretions and excretions is indispensable for determining the proper method of treatment. I would emphasize that the clinical picture of disturbances of internal secretions .should always be kept in mind, for it is very im- portant that they should always be estimated in connection with any other symptom, since upon the proper treatment of this factor usually depends suc- cess or failure. 530 West 144TH Street. A MODIFIED METHOD OF BONE GRAFT. By Julius .'V. Miller, M. D., N\:w York, Lieutenant, U. S. M. U. C. C.\si-. — The patient came to mc for tlie first time nn (Jctober 25, igi6. He had been injured sixty days previ- ously by the collapse of a buildina;, injuries at the time licinK compound comminuted fracture of the tibia and fi1)ula, three inches shove the right ankle joint He was given emergency treatment and ten days later the frac- ture was reduced by open operation in a hospital. A cast was applied from the toes to half way Online Cialis Canada up the thigh. After about fifty days an x ray was taken through the cast and the patient was discharged. Online Cialis Canada He then came under my care. T removed the cast and found there was no union of the fragments. The leg was one inch shorter, tlicrc was an angular deformity of the leg three inches above ankle. tI;o apex of tlic Online Cialis Canada aup.Ie ln-ing posterior, and the ankle was greatly swollen. Landmarks of the ankle were difficult to map out, and the shape of the foot was dis- torted. W'assernirnn test was negative. Ten c. c. of the patient's blood removed from median basilic vein was in- jected to promote union. .A.fter two weeks' immobiliza- tion of the Online Cialis Canada part an x ray was taken with the cast on and nonunion of tibia was found with no callus formation. There was union of the fibula. The lower fragment of Online Cialis Canada tibia was displaced backward and inward with an open space, as shown in the x ray, between it Online Cialis Canada and the upper fragment. There was slight motion at the point of