roid patient is of diagnostic and prognostic interest. Also while the patient is under treatment repeated determinations of the basal metabolism will disclose the success of the treatment. If a determination of the basal metabolism showed that it was not increased, hyperthyroidism and thyrotoxicosis could be excluded. If there was great increase in basal metabolism, hyperthyroidism is in evidence. Increased suprarenal activity may, however, also increase basal metabolism. If the determination showed that the basal metabolism was greatly reduced, hyposecretion of the thyroid could be diagnosed.

Kendall thinks that besides thyroxin the amino acids, protein, creatin and creatinin are also stimulants to basal metabolism. Treatment of Graves' Disease-As prevention is better than cure, it is necessary to carefully study all benign goiters, especially in women, who so regularly during the child-bearing period have this gland normally disturbed. Therefore, as the thyroid normally hypersecretes during menstruation and during pregnancy, if there is a goiter, it may be stimulated to produce toxic symptoms, i.e., it may finally develop into Graves' disease. Hence all causes of enlargement of the thyroid gland should be sought and removed, if possible. Also, iodine or iodide treatment should be instituted, to ascertain if the colloid can be diminished and the gland reduced in size.

If all sources of infection have been removed, or none found, and if an iodide does not cause a benign goiter to become nearly normal in size, its surgical eradication should be considered. This does not mean that every goiter should be removed, but the probability of a patient having trouble from a goiter should be very seriously considered.

At the present time there is a strong feeling that in Graves' disease, in hyperthyroidism, and in thyrotoxicosis operations on the thyroid gland have been too frequent, and that the medical treatment is the safest, and generally offers the best future prognosis. Briefly, the treatment should be absolute rest, mental and physical. The diet should be milk and cereals, perhaps a few green vegetables, later eggs and vegetable proteins. Meat in all forms, and tea and coffee should be prohibited. The patient should receive an extra amount of calcium, besides

what he gets in his milk. Bromides may be, at first, necessary, but soon are not required. The hydrobromide of quinine in large doses has often been successful in quieting the tachycardia. Sometimes the tincture of strophanthus acts well. Thymus gland extracts many times seem valuable in favorably modifying hyperthyroid symptoms. The bowels should move daily, and intestinal fermentation should not be allowed. The diet should be so arranged that gastrointestinal indigestion does not occur. But of all treatments the most important is absolute rest. If in spite of this rest the patient does not do well, the heart continues rapid, and the thyroid is still over-active, other treatments must be considered.

Injections of hot water into the thyroid gland, while at times successful, is not good treatment. Injection of quinine and urea hydrobromide is dangerous treatment. Pressure on the neck and ice applications are not good treatment. There is a difference of opinion as to the value of ligating the thyroid arteries, one or two at a time, on account of the great circulation through the thyroid, although some of the most. able surgeons believe such ligations to be of advantage and life-saving.

Radical operations during an exacerbation of the symptoms seems generally inexcusable. The danger is very great from this extra amount of secretion from the thyroid on account of its action on the heart. If the heart does not quiet, and the symptoms do not abate with rest, the prognosis from thyroidectomy is not good. Also, the more there are lymphoid enlargements, as enlarged tonsils and adenoids, and the more there are lymphatic gland enlargements, the greater the danger from any operation. An enlarged thymus has seemed to increase the danger from the operation, but some surgeons do not think that it ever contraindicates an operation.

Before operative measures should be considered, it is well to try the x-ray treatment of the thyroid. The x-ray has been especially recommended for the treatment of large thymus glands, and we know the thymus can be frequently made smaller by radiations; but it is still a question whether

the thymus gland is adding to the undesired symptoms in Graves' disease, or is trying to combat these symptoms.

Before using the x-ray treatment on the thyroid gland, it should be noted that occasionally the symptoms are made worse by it. Improvement by such treatment is shown by slowing of the heart, increase in weight, diminution of the cerebral irritation, and better sleep. There is no rule as to how long the treatment should be continued. Sometimes, however, the thyroid gland has rapidly changed its activity to a condition of hypothyroidism, and sometimes the x-ray treatment has seemed to have been the cause of death.

Radium treatment of the thyroid is now advised, and many cases of improvement have been noted, but it is doubtful if the success is commensurate with that caused by treatment with the x-ray.

Serums prepared from thyroidectomized animals have been used in hyperthyroidism, but these serums probably represent the solutions of suprarenal, pituitary, and other glandular extracts without the thyroid. Hence they cannot really cause antagonism to hyperthyroidism and may do harm by adding to the blood extra amounts of secretions from these other glands, which glands may be hypersecreting in the patient to whom the treatment is administered.

However much statistics may show that the majority of hyperthyroid patients should not be operated upon, still every surgeon and internist has had patients who, after improvement from medical treatment, could not remain well until after thyroidectomy. Apparently, all patients with severe symptoms of thyrotoxicosis should receive medical treatment only (unless in some cases ligations are advisable), and while the majority of thyrotoxicosis patients may be more or less permanently improved or cured by such treatment, even if they have recurrences, some patients remain chronic invalids until they are operated upon. As above stated, the general trend to-day is to do fewer and fewer operations on patients who suffer from hyperthyroidism; but perhaps more patients should be operated upon who have for the time being benign goiters that may later cause hyperthyroid symptoms.

The better the heart, of course the better the prognosis of operation. If there is myocardial degeneration as determined by symptoms and tests, the risk of operation is great. The length of time the patient has had more or less hyperthyroid symptoms does not seem to be of great importance in determining the operative risk, but the condition of the heart is of primary importance.

Pressure symptoms may call for immediate operation, and a malignant growth of the thyroid gland should generally be surgically removed, unless x-ray treatment is deemed better.

The surgical mortality is greater than has been stated, some patients dying perhaps from a thymus gland pressure, or from an intrathoracic thyroid, others from shock, perhaps from the great amount of thyroxin thrown into the circulation by the nervous excitation before the operation or by careless manipulation of the gland, some because of degeneration of the heart muscle, and some because of a lymphadenoid condition, the so-called lymphatic state. Webster has found that one cause of sudden death after thyroid operations is collapse of the trachea, due to a softening of the cartilage by the long pressure of the enlarged gland. The unsatisfactory after effects are that too many of the parathyroids have sometimes been removed, although this is now rare. Sometimes there is injury to the recurrent laryngeal nerve, with paralysis of the vocal cords. Sometimes, if too much of the gland has been left, it hypertrophies and hyperthyroid symptoms again occur; and sometimes so much of the gland has been removed that hypothyroidism occurs. In other words, the surgical treatment of exophthalmic goiter to-day should not be considered until prolonged medical treatment has been shown to absolutely fail. If necessary, months should be given to the cure of an exophthalmic goiter patient, and even after surgical removal of half or two-thirds of the gland, prolonged medical treatment must be instituted before the patient is cured.

To sum up the treatment of Graves' disease, it may be stated that it is properly a medical disease, and should be medically treated; that if, after prolonged rest and proper management, the heart does not quiet and weight is not gained, and several

examinations of the basal metabolism do not show improvement and the patient is still racing at high speed, the roentgenray treatment, or radium treatment, of the thyroid should be tried for a considerable length of time. If there is no permanent cure from these treatments, at least there will be enough improvement to consider the advisability of surgery. On the other hand, thyroidectomy seems inexcusable during active thyrotoxicosis, when there are signs of cardiac degeneration, when there are signs of much suprarenal associated disease, and when the patient is typically lymphatic.

Hyposecretion. The symptoms of cretinism and of myxedema are well known, but many symptoms caused by hyposecretion of the thyroid are not recognized. Absence of the thyroid, or of its secretion, in infancy causes cretinism. With diminished thyroid secretion in young children, there is slow growth, and a general lack of mental and physical development. Other symptoms from hypothyroidism which may occur at any age are a dry skin, sometimes almost an ichthyosis, and many times eczema, especially around the mouth, nose, and ears, and sometimes chronic eczema in adults. The thyroid secretion is decreased in amenorrhea, in chlorosis, and in the depressant forms of hysteria, and hyposecretion is often one of the causes of the vomiting of pregnancy. Epilepsy developing at the time of the menopause may be associated with subthyroid secretion, and melancholia is frequently associated with hypothyroidism. Adiposis dolorosa and obesity are associated with hyposecretion of the thyroid.

The thyroid normally begins to lessen its secretion after forty-five. At the time of the menopause in women, if its secretion has not diminished, hot flashes, rapid hearts, and general circulatory disturbances are in evidence. If its secretion diminishes too rapidly the woman puts on weight. Also men who, from forty to fifty, rapidly add weight often have hyposecretion of this gland, and senility is closely associated with its hyposecretion. Dry and shriveled skin, hard arteries, diminished general metabolism and sluggish mentality, i.e., senility, is hypothyroidism.

Loss of hair, headaches, and frequently digestive disturbances may be due to hypothyroidism. Sometimes there is profuse