490 EMIL GOETSCH 



in a given patient at a given time (Cistrunk, Du Bois, Sandiford). The 

 metabolic rate parallels closely the clinical picture presented by the pa- 

 tient and also the pulse and pulse pressure. The level of the heat pro- 

 duction is used as an index of the effectiveness of the medical treatment 

 (Du Bois). The metabolic rate has afforded great help in determining 

 the proper method of treatment in conditions of over- or under-activity of 

 the thyroid and, when taken before, during and after treatment, has 

 shown the value of that treatment, whether beneficial or harmful. Simi- 

 larly, the basal metabolism forms a guide for governing this dosage in 

 cases of hypothyroidism (Means and Aub (&)). Again, it has been of 

 great help in the differential diagnosis in obscure cases such as the neuroses, 

 neurasthenia and chronic nervous exhaustion which may simulate hyper- 

 thyroidism but in which there is no definite increase of the metabolic 

 rate. Again, a high metabolic rate is often a warning against surgical 

 measures (Cistrunk) and in those cases in which the metabolic rate is 

 found to be rising, complete rest in bed is indicated together with pre- 

 liminary ligations of the thyroid arteries or treatment with the Rontgen- 

 rays. Again, the metabolic rate when frequently determined enables one 

 to follow the management of the exophthalmic case. The surgeon is also 

 helped, for he is enabled to choose more intelligently the type of operation 

 indicated in a given case. He is also able to decide better as to the amount 

 of tissue to be removed and as to when, in a case in which a complete 

 cure is not obtained, second operation should be done. 



There are certain disadvantages due to technique and interpretation in 

 the application of the basal metabolism test in the diagnosis of hyper- 

 thyroidism. Thus, unless the greatest care is taken to prevent all mus- 

 cular activity, an increase in basal metabolism always results. A sub- 

 stantial error would be introduced if one failed to measure exactly the 

 duration of the observation or allowed escape of air or oxygen around 

 the mouthpiece, or if proper care were not taken to correct the 

 volume of oxygen to zero C. and sea-level barometric pressure. Again, 

 there are some difficulties of interpretation of the metabolic determina- 

 tions, for there are some striking exceptions to what would be warranted 

 suppositions with regard to an individual case. Thus, occasionally a 

 case clearly active clinically fails to show any striking increase in 

 metabolism, and vice versa (Sandiford, Cistrunk). Furthermore, basal 

 metabolism lias been found increased in some conditions other than hy- 

 perthyroidism, as in certain types of endocrin disorders, fever and acido- 

 sis. Thus, for example, Means (b) (1915) found an increase in an un- 

 doubted case of hypopituitarism showing obesity and a high sugar tol- 

 orance. He also found increased metabolism in starvation acidosis as 

 has been found by others in the acidoses of diabetes and in normal sub- 

 jects on a carbohydrate-free diet. Tompkins and Brittingham (1919) 



