HYPOTHYKOIDISM 429 



ing case reported by Magnus-Levy underwent complete thyroidectomy at 

 the age of fourteen. Sexual development did not appear. At the twenty- 

 eighth year, successful thyroid therapy was begun. At the thirtieth year 

 sexual development began and was completed by the thirty-fifth year. A 

 certain degree of sexual maturity was also obtained in the case of a cretin 

 of forty-five. Menstruation sets in again in the female and males may 

 recover their potency. The libido sexualis reappears, 



Clinical Control of Treatment. Certain clinical aids to treatment 

 should be systematically observed and charted in order to obtain the best 

 results. The pulse, temperature and respiration should, if the dose be 

 proper, return to normal in about 10 days' time and remain there. It is 

 doubtful whether it is ever advisable to permit, as did the older clinicians, 

 a state of toxicity to develop with nervous excitability, tachycardia, palpi- 

 tation, tremor, sudoresis and diarrhea. Frequently and even in young 

 subjects a degree of myocardial insufficiency is present in the untreated 

 condition and it is questionable whether more strain should be added to the 

 heart muscle by even permitting tachycardia when it is avoidable. It 

 seems also unnecessary to advise bed rest as did Hertoghe on this account 

 at beginning treatment. A slight acceleration of the pulse rate may be 

 countenanced at the outset but this should not be permitted to persist very 

 long. The writer is accustomed to decrease the dosage should the pulse- 

 rate be found to range 90 or more. 



The reaction to the initial dosage is of much importance. Statements 

 in the literature are in this regard somewhat conflicting, some authors 

 maintaining that subthyroid individuals are more, others that they are 

 less sensitive than normals to thyroid medication. This confusion has 

 arisen from the following causes : First there is an occasional tendency of 

 subthyroid individuals to react violently to even minimal doses. Thus a 

 case of cretinism, a boy of six years, developed great restlessness, precordial 

 pain, tremor of hands, temperature 102, with tachycardia to 135 per 

 minute on % grain of thyroid extract (0.2 per cent iodin) per diem. 

 Some months later the same patient developed a tolerance to 2 gr. thyroid 

 extract daily which had only a therapeutic effect. Most cases of hypo- 

 thyroidism tolerate from the outset much more thyroid substance than do 

 normals. This is true for both mild and severe expressions of the disease. 



Ebntgenological examinations of the epiphyses should be made at 

 intervals of about three months in young subjects during treatment and 

 growth changes recorded ad seriatum. Such rontgenograms are most in- 

 structive. 



The weight curve is of much importance especially in children. It 

 should be charted at about weekly intervals. At first a preliminary fall 

 of weight may be expected which usually lasts but a few weeks at most. 

 If treatment be eificacious thereafter a steady rise in weight together with 

 improvement of the clinical symptoms should then ensue. This should 



