42 THE INTERNAL SECRETIONS—1920 
tion showed a decreased output of urea (1 per cent.). 
Otherwise, it was negative. 
It was evident that the destruction of tissue wastes 
in the patient’s organism, or the catabolism, was very 
much below normal, as compared with the formation of 
tissues, or anabolism, in consequence of which the pa- 
tient keeps on storing up materials, which normally 
should be destroyed in the processes of energy produc- 
tion. 
Remembering the function of the thyroid gland in 
balancing the relation between destruction and recon- 
struction of the tissues, it was assumed that this patient 
was suffering principally from a decrease in thyroid 
secretion. On this ground, thyroid gland was adminis- 
tered. The diet was not reduced or changed. No 
change in pulse rate, blood pressure, or nervous irrita- 
bility was noted with six capsules, amounting to 1% er. 
of thyroid extract a day for a period of four weeks, and 
this fact was thought to be of importance, indicating 
that the patient’s organism was in need of, at least, that 
much more thyroid secretion. However, when the dose 
was increased to 134, gr. per day, the pulse rate rose 
from 76 to 90 per minute, and the blood pressure from 
130 to 135. The patient is now taking only 1 gr. a day. 
Altogether, the patient has been under thyroid treat- 
ment for six weeks and has lost twenty-one pounds. 
CASE No. 4. A man 40 years of age with a negative 
family and previous medical history, consulted me the 
first time for pain in his arms, which had bothered him 
for several weeks. He is a tailor by occupation. The 
physical examination revealed a man 5 feet 5 inches tall 
and weighing only 110 pounds; evidently very much 
underweight and undernourished, with some enlarge- 
ment of the right lobe of the thyroid gland. HExamina- 
tion of the chest revealed a very active apex beat, not 
displaced, but very rapid and irregular. A murmur 
was heard at the apex only and was not transmitted. 
This unusual character of the heart murmur was con- 
firmed by several of my colleagues. The lungs were 
negative. A fine tremor of the fingers was noticed. 
Pulse rate was 105 per minute, and very irregular, as 
shown in the accompanying sphygmographic tracing: 
