340 C. P. HOWAKD 



nation of the blood sugar. He believes that spontaneous hyperglycemia 

 is a very common accompaniment of hyper thy roidism occurring in 90 

 per cent of the moderate and severe cases studied. In mild cases or during 

 latent periods normal blood-sugar values are commonly obtained. Geyelin 

 also adds that either spontaneous or alimentary glycosuria is an equally 

 constant symptom. Alimentary hyperglycemia (two hours after 100 

 grams of glucose) and alimentary glycosuria are found not uncommonly 

 in the very mild cases, whereas fasting or postprandial hyperglycemia 

 and spontaneous glycosuria are usually absent. Finally, Geyelin found 

 that, as compared with normal individuals, there is a slower return to 

 the carbohydrate values of the fasting blood after doses of glucose have 

 been given. 



Dennis and Aub, because of the conflicting findings of Flesch and 

 Geyelin, made blood sugar studies in eighteen patients with hyperthy- 

 roidism and found as did Geyelin alimentary hyperglycemia in every case 

 examined, while fasting hyperglycemia was exceedingly rare. They could 

 find no relation between the degree of hyperglycemia and the intensity 

 of the glycosuria, nor between the severity of the intoxication and the 

 occurrence of hyperglycemia. 



Such then is the chaotic state of our knowledge of the carbohydrate 

 metabolism in Graves' disease ! But this much is certain, that disturb- 

 ances of the thyroid do cause disturbances of the carbohydrate mechanism, 

 but whether directly through the thyroid itself or indirectly through the 

 pancreas is another question. 



Fat Metabolism. This is said also to be occasionally affected, though 

 certainly less frequently and to a less degree than the protein or even the 

 carbohydrate metabolism. Under the gastro-intestinal section we have 

 already referred to a disturbance of fat absorption, resulting in fatty 

 diarrhea. In the same section mention is also made of cases of steator- 

 rhea from an absence or great diminution of the fat splitting ferment 

 from an associated pancreatic disease. We know of no routine, careful 

 investigation of the fat metabolism in any series of cases of uncom- 

 plicated Graves' disease. 



Mineral Metabolism. There is often a phosphorus loss especially 

 through the feces, according to W. Scholz. Falta states that this is re- 

 lated to a calcium loss through the intestines. Clemens found also a 

 chlorid l<;ss in the urine in conjunction with the polyuria. 



Kummcr from a very careful study of one case of exophthalmic goiter 

 found a negative mineral balance during the eleven days' observation; 

 tho patient lost largo amounts of phosphorus and calcium as well as 

 a little magnesium. TTo concludes that the emaciation in exophthalmic 

 goiter is not only caused by loss of fats but also by a loss of minerals. 

 Knnmier further concludes that it is not only a question of malassimila- 

 tion but also of absorption of the ingested mineral material. 



