before puberty has already been described, and such iodine or iodide treatment will prevent the development of simple goiter, to which they are prone if they do not have sufficient iodine in their circulation.

Sometimes thyroid extract in small doses combined with pituitary extract will cure nocturnal enuresis in children, especially if these children show symptoms of lack of develop

ment.

Amenorrhea is of frequent occurrence in women who are not pregnant and is generally associated with more or less muscular weakness, a tendency to sleep in the daytime, more or less indigestion, and with the deposit of fat on the breasts, over the shoulders, on the hips, and sometimes on the upper part of the arms. When this development is excessive, the type of disease termed adiposis dolorosa is in evidence, and that disease is undoubtedly due to a disturbance of the endocrine glands, and is always associated with subsecretion of the thyroid. This disease occurs in all degrees of intensity. At least in all of the moderate types, and generally in the more severe types, thyroid treatment is successful in aiding the patient, and sometimes in curing the condition. As soon as the woman menstruates normally and sufficiently, all the other symptoms are ameliorated; she loses more or less weight although it may not come down to normal. On the other hand, having once shown this type of condition, unless her whole life is changed, either she marries, or she becomes pregnant, or something changes the whole condition of the endocrine glands, she is likely to have recurrences of this condition throughout her life. Sometimes such patients do not menstruate for months, to again begin for a period or two, and then stop again. Whatever the other treatment is, whether ovarian extract, ovarian residue, or corpus luteum, thyroid extract is always of great value. Sometimes an iodide is all that the patient requires. The value of thyroxin for these patients has yet to be determined.

When the menopause develops in women, weight is always added, and if the secretion of the thyroid is too greatly deficient at this time, weight is added rapidly, and more or less symptoms of hypothyroidism occur. Thyroid extract is the treatment for

this condition. The dose required is generally not large, often best associated with an iodide. The pulse is always slow in these subthyroid cases, the skin dry, and there is puffiness under the eyes, on the hands, or on the feet without any actual edema, i.e., there are symptoms of mild myxedema.

If myxedema is really in evidence, the eye-lids are swollen, the teeth decay, the hair falls, hearing becomes impaired, mentality sluggish, the blood-pressure low, the pulse-rate slow, and there are more or less digestive disturbances. Thyroid is the treatment, and it is curative. The dose of thyroid is always less when an iodide is added to it, and thyroxin may be found to be a most successful treatment. The dose of thyroid extract should be sufficient to cause improvement, and after improvement is in evidence the dose should be diminished, and then continued at the amount required to keep the patient normal.

Although there are many causes for obesity that occurs before the age of forty-five or that occurs as an individual condition in a family that is not prone to stoutness, endocrine disturbance is generally at the bottom of the condition. Thyroid feeding for this kind of obesity has often been carried to excess, and has often caused very undesirable symptoms; but associated with the proper diet and the proper amount of exercise, some thyroid treatment is generally advisable, perhaps associated with other glandular extracts. It should always be remembered that with patients who do not show other signs of subthyroid secretion, thyroid treatment may precipitate hyperthyroidism. On this account, many of the so-called obesity cures are dangerous, and the sale of thyroid extract should be subject to the same restrictions as are the narcotics.

Thyroid extract has been given in some of the toxemias, and particularly in the vomiting of pregnancy, and many times it is successful in this condition, although corpus luteum is now suggested for that disturbance; but certainly normal thyroid secretion is necessary for the health of the mother during pregnancy, and if that gland is subsecreting, thyroid should be administered in small doses. Puerperal eclampsia, in which the urine gives no evidence of insufficiency of the kidneys, has been attributed to thyroid disturbance, and certainly in these cases thyroid ex

tract in very large doses has been successful in preventing and stopping convulsions. Also, large doses of thyroid will at times prevent the convulsions of uremia. But thyroid is only a small part of the treatment of the serious condition of either puerperal eclampsia or of uremia, and is only mentioned here to state that all these patients in this serious condition are improved by the administration of thyroid associated with other proper treatment. The dose in these conditions should be 10, 20 or even 30 grains of the extract in the first six hours, and then repeated only as indicated, depending on the results and the symptoms of its action.

At times epileptic attacks are associated with subthyroid secretion, especially the epilepsies which occur at the time of the menopause. Many of these cases may have their actual cause in mouth infection, which has irritated not only the brain, but the thyroid and parathyroid glands. It is possible that the parathyroids are always disturbed in an epileptic attack. Suffice it to say in this connection that cleaning the mouth and throat of infection, the administration of thyroid extract and of calcium salts will always ameliorate and sometimes cure this type of epilepsy. Also, the epilepsies that are aggravated at the time of puberty, or are aggravated during pregnancy should be managed on this same plan. More or less bromides should, of course, be given while the system is righting itself and the irritating substances, or the causes are being eliminated, but to perpetuate the detoxication of the system, unless there is contraindication against it, thyroid should be given with alkaline salts, and especially the calcium salts. All intestinal fermentation and putrefaction should be prevented in these cases, and generally the patients are better without animal proteins. The dose of thyroid in epilepsy cases need not be large, perhaps 0.05 Gm. a day, and if this causes increased heart action the dose should be reduced.

In some forms of digestive disturbances, especially in spastic constipation, small doses of thyroid are beneficial provided such a condition is associated with other signs of subthyroid secretion. Quite probably very small occasional doses of thyroxin will be found to be of great benefit in these conditions, but it

should be emphasized that thyroxin is very potent, and as it is urged that thyroid extract should be given with the greatest of care, it should be more strenuously urged that thyroxin should be given with still greater care.

In increasing blood-pressure as age advances, small doses of thyroid, given daily, or less frequently, especially if the skin is dry and there is tendency to chronic eczema, and the pulse is slow, are of very great benefit. Thyroid secretion is generally what the patient has begun to lack at this age. This evidence of lack of thyroid secretion may occur earlier in life, depending upon what the thyroid has had to do. If it is a woman and she has had many pregnancies, or if it is an individual who has had many serious illnesses, or has had some chronic disease that has caused more or less over-action and finally lessened action of the thyroid gland, thyroid extract is indicated and will be of benefit.

Not infrequently the asthma which occurs in old age is prevented by thyroid, perhaps because it aids in properly combating the irritations from mal-nitrogenous metabolism. At any rate, with high blood-pressure associated with asthma, thyroid is of benefit. Perhaps at times the reason that iodides have been very successful in certain forms of asthma is because they increase thyroid activity.

While theoretically thyroid extract is contraindicated in profuse hemorrhages, as it generally increases such hemorrhages, occasionally in hemophilia thyroid has been curative, but generally it has been a failure. However, in the peculiar hemorrhages seen at the time of the menopause in women, thyroid extract is sometimes a specific. The dose for this condition should be large, for a few days, and then it should be given in daily smaller doses. Sometimes this treatment is successful after all other treatments have failed, it causing cessation of hemorrhage, even when the bleeding has been from the bladder, rectum, mouth, nose, and many other parts of the body.

Thyroid treatment is contraindicated when there are symptoms of hypersecretion of the thyroid, when there are toxic symptoms from hyperthyroidism, when there is sleeplessness, delirium, or any cerebral excitation, when there is a rapid heart

or any irritability of the heart, generally when there are acute inflammations of the skin, and when there is progressive loss of weight.

PARATHYROID GLANDS

The parathyroids are small, kidney shaped, reddish bodies, four in number, two upper and two lower, which are more or less closely associated with the thyroid gland on its posterior aspect. There may be supernumerary parathyroids as there may be a supernumerary thyroid.

Many of the symptoms after thyroid extirpation, long attributed to removal of that gland, are now known to have been due to the coincident extirpation of the parathyroids. Such symptoms are mostly of the convulsive type, and if more than two of the four parathyroids are removed, these symptoms develop and are quickly fatal. The symptoms from parathyroid extirpation are tremors and muscle contractions, more or less tetanic in type. It has been shown that the tetany and cerebral irritations caused by such extirpation are probably due to a deficiency of the calcium in the blood, and the injection of parathyroid extracts or the administration of calcium will prevent or stop the muscular spasms.

Macleod states that Noel Paton's investigations seem to show that the symptoms after parathyroidectomy are due to intoxication by guanidine, and therefore that one of the activities of the parathyroid glands is to prevent the development of this muscle-irritating substance in the body in undue amount. Macleod then draws the conclusion that idiopathic tetany is probably due to an insufficiency of the parathyroid glands.

After partial extirpation of the parathyroids in animals, not sufficient to cause tetany, there is loss of weight, dryness of the skin, eczema and loss of hair.

The close association of the parathyroids with the thyroid would suggest their physiologic relationship to each other, and, though they have been found abnormal in thyroid disease they cannot assume the functions of the thyroid, however closely they may be associated with it in certain chemical relations. It would seem that the different forms of tetany and some of