Hyperthyroidism

QRAVES' Disease -or Hyperthyroidism has presented many problems, the solution of which has demanded the activity of all departments of scientific medicine, and to which each has. contributed its quota of valuable information. The internist has of late years been especially interested in the study and detection of mild grades of the conditions causing more or less pronounced invalidism and simulating other diseases. The chief problem affecting the surgical treatment has been, however, the development of a pre-operative preparation, an operative technique; and a postoperative care by which the margin of safety to the patient has been progressively increased. Biological chemis. try in the study of metabolism now permits empiric expe'rience to be interpreted in terms of scienttific exactitude. In Kocher's epochal work upon goitre we view the efforts of this master surgeon and clinician to discover a safe criterion for operation upon goitre cases associated with hyperthyroidism and the enunciation of definite rules of surgical procedure. Kocher recognized the value of refrigeration; employed exercise as a test of myocardial stability; sought in the differential leucocyte count an index of the gravity of the toxoemia; and resolutely set his face against the use of inhalation ancesthesia. Although the differentiation between cases of Graves' disease and toxic adenoma had not clearly emerged, Kocher furthdr found by experience that the radical operation of that day (lobectomy) could not be undertaken safely as a routine, and advocated vascular ligation, first practised by Wolfier, as a preliminary measure in the more serious cases. Barker of University College Hospital, London, measurably advanced upon Kocher's cocaine analgesia by using beta eucaine and an improved method of infiltration. Still the mortality following operation remained high. The severe and often fatal reactions following operation were variously ascribed t'o (1) nervous shock; (2) compression of the glantd during operation; (3) absorption of liberated thyroid secretion from the divided surfaces of the gland; (4) haemorrhage; and (5) infection. Crile met all these conditions with a technique which eliminated the unexpected, the chief cause of nervous excitation; reduced traumatism to the irreducible minimum; and advocated combined local and gas-oxygen anaesthesia. As a result the mortality figures rapidly declined. The latest and greatest advance is due to the clinical application of important laboratory discoveries. The names of Lavoisier, Rubner, Benedict, DuBois, and Tissot are closely associated with the development of apparatus and technique for the estimation of the basal metabolic rate in animals and man, and for substantiating what has long been assumed, that the thyroid is the chief regulator of chemical activity with-