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gh…speed （trauma and fear）； and if the accelerator be used as well （thyroid secretion？）； though the machine will not move； not only will the battery soon be exhausted； but the battery elements themselves will be seriously damaged （exhaustionsurgical shock）。
We have now presented some evidence that nervous energy is discharged by the adequate stimulation of one or more of the various receptors that have been developed in the course of evolution。 In response to an adequate stimulus； the nervous system is integrated for a specific purpose by the stimulated receptor； and but one stimulus at a time has possession of the final common path the nerve mechanisms for action。 The most numerous receptors are those for harmful contact； these are the nociceptors。 The effect of the adequate stimulus of a nociceptor is like that of pressing an electric button that sets great machinery in motion。
With this conception； the human body may be likened to a musical instrumentan organthe keyboard of which is composed of the various receptors； upon which environment plays the many tunes of life； and written within ourselves in symbolic language is the history of our evolution。 The skin may be the 〃Rosetta Stone〃 which furnishes the key。
Anoci…association
By the law of phylogenetic association； we are now prepared to make a practical application of the principles of the discharge of nervous energy。 In the case of a surgical operation； if fear be excluded and if the nerve…paths between the field of operation and the brain be blocked with cocain；＇*＇ no discharge of energy will be caused by the operation； hence no shock； no exhaustion； can result。 Under such conditions the nervous system is protected against noci…association； resulting from noci…perception or from an adequate stimulation of nociceptors。 The state of the patient in whom all noci…associations are excluded can be described only by coining a new word。 That word is 〃anoci…association〃 （Fig。 14）。
＇*＇ See footnote； page 4。@@@
The difference between anesthesia and anoci…association is that； although _inhalation anesthesia_ confers the beneficent loss of consciousness and freedom from pain； it does not prevent the nerve impulses from reaching and influencing the brain； and therefore does not prevent surgical shock nor the train of later nervous impairments so well described by Mumford。 _Anoci…association_ excludes fear； pain； shock； and postoperative neuroses。 _Anoci…association_ is accomplished by combining the special management of patients （applied psychology）； morphin； inhalation anesthesia； and local anesthesia。
We have now presented in summary much of the mass of experimental and clinical evidence we have accumulated in support of our principal theme； which is that the discharge of nervous energy is accomplished in accordance with the law of phylogenetic association。 If this point seems to have been emphasized unduly； it is because we expect to rear upon this foundation a clinical structure。 How does this hypothesis apply to surgical operations？
Prevention of Shock by the Application of the Principle of Anoci…association
Upon this hypothesis a new principle in operative surgery is founded； _i。 e_。； operation during the state of _anoci…association_。 Assuming that no unfavorable effect is produced by the anesthetic and that there is no hemorrhage； the cells of the brain cannot be exhausted in the course of a surgical operation except by fear or by trauma； or by both。 Fear may be excluded by narcotics and special management until the patient is rendered unconscious by inhalation anesthesia。 Then if； in addition to inhalation anesthesia； the nerve…paths between the brain and the field of operation are blocked with cocain；＇*＇ the patient will be placed in the beneficent state of _anoci…association_； and at the completion of the operation will be as free from shock as at the beginning。 In so…called 〃fair risks〃 such precautions may not be necessary； but in cases handicapped by infections； by anemia； by previous shock； and by Graves' disease； etc。； anoci…association may become vitally important。
＇*＇ See footnote； page 4。@@@
Graves' Disease
By applying the principle of the discharge of nervous energy by phylogenetic association； and by making the additional hypothesis that in the discharge of nervous energy the thyroid gland is stimulated through the nervous system； we can explain many of the phenomena of Graves' disease and may possibly discover some of the factors which explain both its genesis and its cure。
In the wild state of animal life in which only the fittest survive in the struggle for existence； every point of advantage has its value。 An animal engaged in battle or in a desperate effort to escape will be able to give a better account of itself if it have some means of accelerating the discharge of energy some influence like that of pouring oil upon the kindling fire。 There is evidence； though perhaps it is not conclusive； that such an influence is exerted by the thyroid gland。 In myxedema； a condition characterized by a lack of thyroid secretion； there is dulness of the reflexes and of the intellect； a lowered muscular power； and generally a sluggish discharge of energy。 In Graves' disease there is an excessive production of thyroid secretion。 In this disease the reflexes are increased； the discharge of energy is greatly facilitated； and metabolism is at a maximum。 The same phenomena occur also after the administration of thyroid extract in large doses to normal subjects。 In the course of sexual activities there is an increased action of the thyroid； which is indicated by an increase in its size and vascularity。 That in fear and in injury the thyroid； in cases of Graves' disease； is probably stimulated to increased activity is indicated by the increased activity of the thyroid circulation； by an increase in the size of the gland； by the histologic appearance of activity in the nuclei of the cells； and by an increase of the toxic symptoms。 Finally； Asher has stated that electric stimulation of the nerve supply of the thyroid causes an increased secretion。 The origin of many cases of Graves' disease is closely associated with some of the causes of the discharge of nervous energy； depressive influences especially； such as nervous shocks； worry and nervous strain； disappointment in love； business reverses； illness and death of relatives and friends。 The association of thyroid activity with procreation is well known； hence the coincidence of a strain of overwork or of fear with the sexual development of maturing girls is obviously favorable to the incidence of Graves' disease。 The presence of a colloid goiter is a suitable soil for the development of Graves' disease； and I fully recognize also the evidence that infection or auto…intoxication may be contributing factors and must be assigned their role。
I have never known a case of Graves' disease to be caused by success or happiness alone； or by hard physical labor unattended by psychic strain； or to be the result of energy voluntarily discharged。 Some cases seem to have had their origin in overdosage with thyroid extract in too vigorous an attempt to cure a colloid goiter。