CLINICAL SYNDROMES 337 



heat. At least a part of the tachycardia is due to the increased metabolism. 

 There is evidently no interference with the oxidation of carbohydrates. 

 The average water elimination through the skin and lungs in the severe 

 and moderately severe cases is 39.9 grams per hour. This increase above 

 the normal is closely proportional to the increase in heat production; 

 25.7 per cent of the calories are dissipated through vaporization in 

 goiter patients, whereas the mean normal is about the same or 23.9 per 

 cent. Means and Aub (a) state categorically that "while a rise may be 

 likewise found in a few other pathologic conditions, it is less marked and 

 is found in conditions easily differentiated from hyperthyroidism." It 

 seems fair to say that a rise in the basal metabolism is not only a con- 

 stant feature but is one of the most striking and characteristic mani- 

 festations of thyroid overactivity. This rise, therefore, may be used 

 as a functional test of the thyroid activity or as an index of the intensity 

 of the thyroid intoxication. Rest alone usually caused a marked de- 

 crease in the toxicity. Drugs do not materially accelerate this decrease. 

 In some cases the Rontgen-rays produce a definite improvement; in 

 others they are without effect. The usual immediate effect of surgery is 

 a very definite decrease in toxicity, but there is often a subsequent 

 recurrence. 



Emaciation. The marked and rapid emaciation is an almost con- 

 stant symptom in spite of the large food intake. It was noted by Murray 

 in more than one-third of his 180 cases. This loss of weight varies from 

 fifteen to thirty pounds and may rise nearly to sixty pounds. In a 

 case reported by Mannheim there was a loss of ninety-three pounds in 

 ten months. In very severe cases it may amount to one-third or even 

 half of the original body weight. It usually develops before the diarrhea 

 and vomiting, but is always made worse by these. Huchard has de- 

 scribed "crises of emaciation' which may be followed by a gain in weight 

 almost as rapid and marked as the loss ; thus one patient gained back in 

 ten weeks thirty-three of the sixty-two pounds that had been lost in 

 one year; the gain in weight may take place in spite of the persistence 

 of diarrhea and other symptoms of hyperthyroidism. The emaciation 

 is due to the thyroid intoxication, which in part accounts for its great 

 variation in the different cases. 



Fever. 7 ever of different degrees of severity and duration was 

 first extensively reported by Bertoye in 1888. In some cases, according 

 to this authority, it may resemble the fever of typhoid and may be asso- 

 ciated with other symptoms of fever. Mackenzie (&) states that the eleva- 

 tion in temperature does not exceed as a rule one or one and a half 

 degrees Fahrenheit. "I have had observations made in a great number 

 of cases and find that a temperature above 100 F. is quite exceptional." 

 Thompson noted fever above 99 F. in thirty-nine cases, of 101 to 

 104 F. in fourteen and above 104 F. in seven cases of a hospital 



