In June, 1914, he had an attack of dull pain in the course of the first left metatarsal bone. The pain was constant, kept him awake; but was unaccompanied by swelling. This lasted three days. In December, 1914, he had an attack of acute coryza and acute bronchitis. In January, 1915, he had an attack of headache. In May he had pain in the left knee, fever to 100°, with diffuse pharyngitis and aphthous stomatitis, which lasted about ten days. In June he had an attack of pain in the left shoulder and left chest, with nervousness. In November he had an attack of coryza and arthritis of the left ankle with fever to 100.4°. In April, 1916, he had an attack of pain and swelling of the right ankle with fever to 101°, followed by a diffuse stomatitis. In February, 1917, he had an attack of pain in the left foot and right knee. In July, an attack of acute tonsillitis. During the winter of 1919-1920 he had two attacks of arthritis and one of bronchitis. In September, 1920, he had an attack of acute dyspeptic diarrhea. In January, 1921, the left first tarso-metatarsal joint and the left knee were painful and swollen and the right first metatarsophalangeal joint was painful. In September, after having taken a quantity of thyroid substance estimated at 35 ounces since the beginning of treatment, he had an attack of acute nervousness and complained of his arm trembling when he tried to write. At this time he also began to complain of pain in the left shoulder. The pulse was irregular and suggested pulsus irregularis perpetuus. There was a well marked tremor in the hands. His thyroid substance was stopped and the irregularity disappeared. An electrocardiogram had been made in December, 1920 (fig. 1) and it was suggested that the examination be repeated; but the arrhythmia stopped so soon after the discontinuance of the thyroid substance (less than ten days) that he decided not to undertake it. In October, 1921, he complained of soreness in the left knee. By November 3, he had increased 15 pounds in weight and the thyroid substance, which had been discontinued in September, was again given. On July 4, 1922, after he had taken an additional quantity of thyroid substance estimated at 870 grains, he complained of pain in the left knee of three or four days duration. His heart action was found to be irregular. An electrocardiographic examination confirmed the suspicion that the irregularity was due to auricular fibrillation (fig. 2). The thyroid substance was again stopped and a third electrocardiograph was made nineteen days later, (fig. 3) which showed a normal rhythm. On August 7, he had gained 21 pounds in weight and thyroid substance was again given in doses of 2 grains a day. He took this dose for twenty-nine days or 70 grains, when, although there were no indications of cardiac disturbance, the dose was reduced to 2 grains every other day. He had lost a little weight (2 pounds), and it was thought it would be best to use just enough thyroid substance to keep him from gaining. On September 19, however, after he had taken 14 grains more of thyroid substance, he reported complaining of precordial pain, maximum intensity in the third left interspace, radiating to the back. The heart rate was 106; pulse rate FIG. 2. ELECTROCARDIOGRAM. JULY 7, 1922. MADE BY DR. JOHN J. FINNEGAN Lead I. P wave absent. R-1 present, measures 11 mm. S-1 present; measures 4 mm. Q-R-S complex measures 0.05 second. T-1 upright, measures 2 mm. Fibrillary waves seen in diastolic period. Lead II. P-2 absent. R-2 measures 17 mm. Q-R-S complex measures 0.06 second. S-2 measures 3 mm. T-2 broad, positive; measures 5 mm. Fibrillary waves in diastole. Lead III. P-3 absent. R-3 positive; variable, from 10 to 12.5 mm. Shows splitting on the upstroke. Q-R-S complex measures from 0.06 to 0.08 second. T-3 positive. Fibrillary waves in diastole. Diagnosis; Auricular fibrillation. FIG. 3. ELECTROCARDIOGRAM. JULY 26, 1922. MADE BY DR. JOHN J. FINNEGAN Lead I. P-1 positive. P-R interval 0.18 second. Q-R-S complex measures 0.06 second. R-1 and T-1 both present and positive. S-1 present. Lead II. P-2 positive. P-R interval 0.21 second. Q-R-S complex measures 0.06 second. R-2 and T-2 positive. S-2 present. Lead III. P-3 positive. P-R interval 0.21 second. R-3 positive, split on the upstroke T-3 positive; S-3 absent. Diagnosis. Prolonged P-R interval. Right ventricular preponderance (Potential difference slight). 315 80, deficit 26. The pulse was of the pulsus irregularis perpetuus type. The thyroid substance was again discontinued and in four days the heart action had again become regular and the heart action and the pulse were regular. On December 21 he had gained. twenty-two pounds in weight over his weight on July 24 and he was put on the 2 per cent thyroid nucleo July, 1914 November, 1914 May, 1916 April, 1918 June, 1919 June, 1919 June, 1919 September, 1919 May, 1920 September, 1920 September, 1921 January, 1923 January, 1924 May, 1924 Thyroid substance gr. T.D. Thyroid substance gr..ii T. D. 210 220 Thyroid Nucleoproteid 2% begun CHART I. VARIATIONS IN WEIGHT OF THE PATIENT pulse deficit had disappeared. During September and October he had some pain in the left acromioclavicular joint. A tooth was extracted on November 3. On that day there was a pulse deficit of twelve but the proteid as prepared in the Laboratories of the Cornell University Medical School. In February, 1923, he again began to complain of pain and swelling in both knees and both feet, no fever. He was in bed from Feb |