METABOLIC RATE AND THYROID FUNCTION FOLLOWING ACUTE
THERMAL TRAUMA IN MAN*
OLIVER COPE, M.D., GEORGE L. NARDI, M.D., MANUEL QUIJANO, M.D.,
RICHARD L. ROVIT, M.D., JoHN B. STANBURY, M.D., AND ANNE WIGHT, M.D.
BOsTON, MASSACHUSETTS
FROM THE SURGICAL RESEARCH LABORATORIES OF THE HARVARD MEDICAL SCHOOL AT THE MASSACHUSETTS GENERAL HOSPITAL, THE
THYROID CLINIC, AND THE SURGICAL SERVICES OF THE MASSACHUSETTS GENERAL HOSPITAL, BOSTON, MASSACHUSETTS
WASTNG OF THE PATiENT is a sequel of
a severe burn. This wasting is accompanied
by an outpouring of nitrogen through the
kidneys in the initial weeks after injury.
Recent interest in the response of the
adrenal cortex to trauma has led to an impression that both the was-ting and increased excretion of nitrogenous products
are due to the catabolic effects of an abrupt
rise in secretion of adrenal cortical hormones.5 8, 11, 15, 16
Clinical observation of the severely
burned patient suggests that there might
well be factors in addition to an increased
adrenal cortical action leading to body
wasting. Infection is a complication of a
severe burn, and infection breeds fever and
cell breakdown. Amenorrhea and loss of
libido indicate a wider disturbance of pituitary function than simple adrenal stimulation. Since wasting and some fever are
accompaniments of hyperthyroidism, it is
possible that thyroid function may also be
accentuated.
Because of these various possibilities, and
particularly the last, a study of metabolic
rate and thyroid function was undertaken
in patients who have been subjected to the
severe stress of extensive burns.
PLAN OF OBSERVATIONS
The thyroid function and metabolic activity of patients who have been exposed
to the trauma of burns has been studied
throughout the natural history of the burn
wound, its complications and consequences.
The effects of severe thermal injury have
been compared with those of lesser magnitude, of operations for common surgical
diseases, and of a high protein diet.
TH
PATIENTS
The Severely Burned. The studies on 12
severely burned patients form the kernel of
this report. Ten of the 12 were brought to
the Massachusetts General Hospital in the
first few hours after injury. One arrived 24
hours after injury. One patient, case 50-20,
was transferred to this hospital 11 weeks
following his trauma. All 12 of these patients had suffered extensive thermal injury
involving from 20 to 68 per cent of their
body surfaces. Many of the burned areas
were of full-thickness destruction and required grafting. There was one death, case
51-14, a patient who developed renal failure and expired on his twelfth hospital day.
The patients were adults, their ages varying from 18 to 60. All, with one possible
exception, were believed to have been in
* This work was supported by a Contract be- good nutritional state prior to injury. The
tween the Office of Naval Research and Harvard possible exception, case 51-89, was a chronic
University, and grants to the Thyroid Clinic from
of 29 who, despite her
Parke-Davis Company and the H. N. C. Fund of alcoholic, a woman
normal
fat deposits and no
had
history,
Harvard Medical School. Submitted for publication
vitamin
of
clinical
deficiency.
evidence
1952.
August,
165
COPE, NARDI, QUIJANO, RO'VIT, STANBURY AND WIGHT
The Moderately Burned. Three patients,
ages 44, 49, and 75, had burns of lesser
extent. The total areas involved ranged
from 15 to 20 per cent. All survived. They
were studied to observe the effects of a
less severe thermal injury.
The Unburned. Thirteen unburned patients were studied as controls. Six of these
13 were observed before and after major
surgical procedures of varying magnitude.
The operations consisted of two herniorrhaphies, two hysterectomies, one vagotomy, and one unilateral adrenalectomy for
Cushing's disease. The patients withstood
their operation well. There were no deaths.
The observations indicate the effect of operative trauma and the postoperative regimen on basal oxygen consumption.
Six of the unburned were patients with
perforated peptic ulcers. They entered the
hospital and their perforations were closed
within the first hours after perforation.
Their metabolic rates were determined
from the day after perforation until discharge from the hospital ten to 12 days
later. The observations show the effect of
a chemical peritonitis, the superimposed
operative trauma, and the pre- and postoperative regimens. In these patients, the
intravenous part of the pre- and postoperative regimes closely approximated
that given several of the severely burned
patients. They included saline, glucose,
plasma, whole blood and amino acids.
The thirteenth unburned person was a
young, healthy, adult male who volunteered
to serve as a dietary control. In him was
observed the effect of the high protein diet
fed many of the burned patients for long
periods of time.
The burned patients and those with the
perforated ulcers were cared for in the
metabolic unit provided for the study of
trauma at the Massachusetts General Hospital. The studies on many included balances of nitrogen, sodium, potassium, chlorides, calcium, phosphorus, steroid excretion
Annals of SurgerY
patterns, and repeated eosinophil counts.
These are described elsewhere.7 16
The other non-burned patients were
cared for on the General Surgical Services
of the Massachusetts General Hospital.
Metabolic Rate Determinations. All of
the burned patients reported here had multiple metabolic rate determinations, beginning in some cases on the day following
trauma and extending in one case to as
long as 17 months after the original injury.
The studies on those patients with facial
burns had to be delayed until healing permitted the use of a nose clip and mouth
piece.
Of the unburned, the six patients who
were to undergo major surgery had two to
three determinations of their metabolic rate
preoperatively. Subsequent to operation,
daily measurements were carried'out until
the eighth to twelfth day following operation.
The rate of oxygen consumption was
measured in the first waking hours in the
morning, the usual time for the measurement of the basal metabolic rate in patients being observed for thyroid disease.
All patients were fasting, in that they had
not eaten since the evening before. A few
observed in the first days after the burn or
operation, however, had received an intravenous injection during the night, a necessity of fluid management.
The sleep of the burned and early postoperative patient is often disturbed. Thus
the emotional state in some of these patients did not always correspond to the
accepted standards for the determination
of the basal metabolic rate. In order to
minimize these disturbing influences, the
metabolic rates of the burned and perforated ulcer patients were measured in
the patient's own room, a single room, with
the patient remaining in bed. These same
considerations were given the patients undergoing the other surgical operations except that the patients often were not in a
166
Volume 137
Number 2
THYROID FUNCTION FOLLOWING ACUTE THERMAL TRAUMA
single room. All the determinations were
made by the same technician.
The metabolic rate was calculated from
the oxygen consumption by the DuboisAub surface area formula,1 and tests with
an irregular respiratory line were discarded.
Specific Measurements of Thyroid Function. The protein-bound iodine of the serum
+9W
+0
had two such determinations of PBI and
1131 uptake, and one patient had three separate periods in which his oxygen consumption, PBI, and 1131 uptake were studied
together.
Judged by their medical history and the
finding of a normal thyroid gland on physical examination, all the patients- are considered to have been euthyroid prior to injury. None of the patients had received iodine in bound form for Graham-Cole or
pyelographic tests, and therefore the PBI
+70CASE 5i - 4 3
50A
+6
>45 /
W*-40
;a
+
12
.
\
35
METABOLIC RATE
2!F
* PB 46y
I 4:
40
\
PI
52
y
v
e
i.
0
-
D
30 40
50
60
UPTAKE
I, XSS
20
3D 40 50 O0 70 80 90
OAYS POST
00
110
10001405060
10000
Wno
FIG. 2.-( Case 51-43). Metabolic rate and
thyroid function in a 30-year-old male following
extensive thermal trauma. The metabolic rate was
plus 30-50 for the first 2 months following injury-;
It diminished to plus 5-15 three to four months
after the original trauma when wound healing was
well advanced. It was 0 on discharge, 205 days
after admission. Despite this elevation in the first
months after injury, his thyroid function was normal on the 28th day and remained virtually unchanged at the time-of his discharge 5 months later.
This 30-year-old male suffered a total body
burn of 68 per cent, including much full thickness
sldn destruction, when his clothing was ignited by
the explosion of an electric light bulb accidentally
inserted into a high voltage line.
-0.
e
11
_S
_S
39_
O
708 0
DAYS POST BURN
FIG. 1.-The course of the metabolic rate of 11
extensively burned patients in the initial weeks
after injury. The levels of oxygen consumption are
comparable to those associated with severe thyrotoxicosis. Only two patients had metabolic rates in
the normal range at any time in the first 23
months after trauma, and both of these patients
had elevated initial values and low normal values
is believed to represent the actual level of
later when healed.
The burns in these patients ranged in extent circulating thyroid hormone. Clinical defrom 20-68 per cent, and included large areas of
termination of protein-bound iodine was
full-thickness destruction.
and the uptake of I131 by the thyroid gland
was measured in eight of the severely
burned patients, and in one patient, case
52-27, who had burns of limited extent.
These measurements of protein-bound iodine and I13l uptake may be considered as
specific for thyroid function, in contrast to
the oxygen consumption which is subject
to many influences other than that of the
thyroid hormone. Seven of the nine patients
done by the Riggs modification of the
Barker method.3
The I131 uptake in the thyroid gland was
measured 48 hours after a tracer dose, usually 5-20 microcuries, had been administered orally. In the majority, the measurement was taken over the thyroid gland
with a directional counter, but in patients
too ill to be moved for direct counting, the
48 hour urinary excretion was determined,
the percentage of radioactive iodine picked
167
COPE, NARDI, QUIJANO, ROVIT, STANBURY AND WIGHT
Anals ot Surgery
February, 1953
by the thyroid gland being calculated metabolic rates of plus 30 to plus 50 in
the first two months after his injury (Case
the reciprocal.
51-43, Fig. 2). These elevated rates reOBSERVATIONS
ceded to normal only after 115 days, a time
Metabolic Rate
when
The Severely Burned. The course of the way. healing of his wounds was well under
metabolic rate of 11 severely burned patients is shown as a composite graph (Fig.
up
as
I
CASE 51-89
0
20
30
4
DAYS POSt BURN
FIG. 3.-( Case 51-89). Metabolic rate and
thyroid function in a 29-year-old female following
extensive thermal trauma. The metabolic rate
ranged from plus 16 to 47 for the first two weeks
following injury. When seen again 4% months
later on a later hospital admission after her primary
wounds had healed, her metabolic rate was recorded as minus 10. Despite this initial period of
metabolic rate elevation, her thyroid function as
measured on the 4th day following trauma and
repeated 5 months later, was found to be in the
normal range.
This 29-year-old female, a chronic alcoholic,
suffered a 20 per cent body bum involving both
upper extremities and one flank, when her clothing
was ignited from a mislaid cigarette. Practically
all of her bumed areas were of full thickness destruction. Both forearms had to be amputated.
"VYS POT
Beia
FIG. 4.-(Case 50-20). Metabolic rate and thyroid function in an 18-year-old male following extensive thermal trauma and after therapy which
included ACTH. This 18-year-old boy suffered
burns of the entire lower extremities after a kerosene explosion ignited his clothes. He was treated
at another hospital, and transferred to the Massachusetts General Hospital 11 weeks after injury.
His therapy at the other hospital included 1550
mgm. of ACTH in 69 days. When first seen at the
Massachusetts General Hospital, he was emaciated,
debilitated, and presented large open granulations
of both lower extremities.
His metabolic rate on the 100th day following
trauma was plus 10. Repeated determinations on
his 220th to 260th day revealed rates of minus 35
to minus 48. On a subsequent hospital admission
for the treatment of a persistent dermatitis of
both lower extremities, his metabolic rate ranged
from minus 5 to minus 21, 500-521 days following
his bums.
Despite this extensive depression of metabolic
rate seven and eight months after trauma, his
1). The metabolic rate following an extensive burn is high,, in the plus 30 to plus
60 range, many for as long as two months
post trauma. The rates of only two of thyroid function as measured by PBI and Il31
were normal. Again thyroid function measthe 11 patients could be considered to uptake
ured seventeen months after injury, before and
ten
have been in the normal range of plus
after ACTH therapy for his dermatitis, revealed
to minus ten. In both these patients, the normal values.
initial levels were above normal; gradually
the levels receded to minus ten by the
thirty-fifth and seventy-second days after
injury respectively.
The course of the metabolic rates of two
patients typical of this group are depicted
in detail in Figures 2 and 3. The first, a
young 30-year-old male with a total burn
of 68 per cent of his body surface, had
is
The pattern of metabolic
unusual.
response
in this
case
The second, a 29-year-old female, had
suffered a burn of 20 per cent, all of full
thickness (Case 51-89, Fig. 3). Her metabolic rates were elevated during the first
weeks after injury, and returned to the
normal range five months after her original
trauma, when she was fully healed.
168
THYROID FUNCTION FOLLOWING ACUTE THERMAL TRAUMA
Volume 18l
Number 2
An exception to the elevated metabolic
rate during wound healing was encountered in an extensively burned boy of 18
(Case 50-20, Fig. 4). He had been transferred to the Massachusetts General Hospital from another hospital 11 weeks after
injury, and after therapy which had included continuous ACTH. When first seen
here, he was emaciated, and his wounds
were severely infected. Each lower extrem-
on the fifth to ninth postoperative days
were lower than the preoperative level.
The metabolic rates of the six patients
with perforated ulcers are shown in Figure
7. In the first three days after perforation
and operation, the rates are elevated, much
as in the severely burned, but the rates
decline promptly to normal thereafter.
The possible specific dynamic effect of
the high protein diet on the metabolic rate
.30
.w
/. STERECTOMY
..0
----
I
\
\
/
¢
/^'
I
--,ADRENAkLECTOMtY
~~~~~VAGOTOM Y
'+
<
y
a:
a
-
-
.-
lo,
X -*0~--.. 03 3
\
E3RN2
AY
v
-
H3C~3ERNY
t
-3
2
DAYS POST BURN
@
fi
2
z
5
6
8
9
e
§
DAYS5 POST OPERATION
FIG. 5.-The course of the metabolic rate of
three moderately burned patients in the initial
weeks following trauma. The burns were mainly
full-thickness, circumscribed, and involved 5 to 20
per cent of the total body surfaces. The metabolic
rates are normal, or only slightly elevated, plus 12
to plus 30, in the initial weeks after injury.
FIG. 6.-The metabolic rates of six patients undergoing major operations. The metabolic rate rose
slightly immediately following surgery, descending
to the pre-operative level by the Sth-7th postoperative day. In two patients, the level on the 7th
postoperative day is slightly lower than before
granulating, open
wound. During the period of 220 to 250
days after injury when his wounds were
being grafted and his eosinophil counts
were low, his metabolic rate was minus 30
to 48. Because he was not observed in the
initial weeks after injury, his data are not
included in Figure 1.
The Moderately Burned. The metabolic
rates of the three patients with the circumscribed burns are shown in graphic form
in Figure 5. They are normal or only slightly
elevated in the first weeks after injury.
The Unburned. The metabolic rates of
the six patients who had undergone major
surgical procedures are depicted in Figure
6. All determinations before and after the
trauma of operation fell in the accepted
normal range. Immediately following operation, there was a slight rise in rate descending to the preoperative level by the
5th to 7th postoperative day. In two, those
who underwent herniorrhaphy, the rates
of the non-burned volunteer is shown in
Figure 8. Fed an approximately constant
caloric intake, the protein part of the intake was shifted from high to low and back
again. Throughout the period of observation he lived close to the hospital and
worked as a laboratory technician. A tall,
lean fellow, he gained slightly in weight.
The average metabolic rate is slightly lower
while on the low protein diet. There is an
abrupt rise in rate upon resumption of the
high protein intake. A similar abrupt rise
was seen earlier, and the changes are therefore considered not significant. Throughout- the 36 day period of study, the metabolic rate stayed within an acceptable normal range. It is concluded that the change
in diet was without recognizable effect.
Protein-bound Iodine. The level of protein-bound iodine in the circulating blood
was determined in periods ranging from 1
to 516 days after trauma in eight of the
severely burned patients and one of the
ity was
one
great oozing,
operation.
169
Annals of Surgery
February, 1953
COPE, NARDI, QUIJANO, ROVIT, STANBURY AND WIGHT
moderately burned. All except one of the
determinations fell in the normal range
(Fig. 9). The exception, the earliest recorded on the chart, was 3.2 gamma/100
cc., the accepted normal range being 3.5
healed stage of the burn. There was also
constant tendency to depart from the
level of thfe protein-bound iodine. The determinations in five of the patients are also
depicted in Figures 2, 3, 4, 10, and 11.
no
to 8.0 gamma. In those patients with reOBSERVATIONS
EVALUATION OF
peated determinations, there was no constant tendency toward elevation or depresThe oxygen consumption, or metabolic
sion as the burns progressed from the acute rate, of the severely burned patient is
THE
0O12
3' 4 5 6 7 8 9
DAYS AFTER PERFORATION
10
II
12
5
l0
20
5
25
30
5
DAYs
FIG. 7.-The metabolic rate of six patients who
suffered a perforated ulcer. The perforated ulcer of
each patient was sutured surgically within the first
hours after perforation.
to the healed state. The determinations
made in 5 of the 8 severely burned patients
are separately depicted in Figures 2, 3, 4,
10, and 11.
I131 Uptake. The uptake of I131 by the
thyroid gland was also measured in the
same eight extensively burned patients and
one moderately burned patient in whom
the PBI levels were determined. The 1131
uptake and PBI levels were usually measured at approximately the same time. All
the determinations are plotted with the
protein-bound iodine level in Figure 9. The
scattering was somewhat greater than that
observed in the PBI levels. One determination fell below and two above the normal
range of 20 to 55 per cent uptake for people living in iodine-sufficient New England.
Multiple determinations in the same patient, as with the PBI level, showed no constant tendency to elevation or depression as
the patient passed from the acute to the
FIG. 8.-( Case Control No. 1 ). The lack of
effect of the specific dynamic action of a long continued high protein diet on the basal metabolic rate
of a normal individual. A young, healthy, adult
male volunteer was fed a high protein alternating
,nInrit intnlf!
IVIM211
111MAC; rtmainVYitLh aa In.u
jnrJtpin Zipf
11w UMV11t
l\JW iJ^VLuil
Wltll
UIUL, thp.
constant. Although there is a suggestion that
the basal metabolic rate declined slightly when on
the low protein diet, and rose again upon resuming
the high protein diet, comparable changes were
seen at other times while on the high protein diet.
ing
typically elevated during the initial weeks
following injury. This elevation is of a
degree comparable to moderate or severe
thyrotoxicosis. Not until wound healing is
virtually complete does the rate revert to
normal. The rise in oxygen consumption
exhibited by these patients appears to be
roughly proportionate to the severity of the
burns; it is of minor degree in patients
hospitalized with bums of limited extent
and depth.
The genesis of the elevated metabolic
rates of the severely bumed patient may
have multiple causes including theoretically
an increased activity of certain .of the endocrine glands, the specific dynamic action
of the high protein diet fed these patients,
170
Volume 137
Number 2
THYROID FUNC'rION FOLLOWING ACUTE THERMAL TRAUMA
fever, and the increased local metabolism
of the wounds. Of the endocrine glands, the
first to suspect is the thyroid. That the high
metabolic rate is not due to overactivity of
the thyroid is indicated by the repeated observations of a normal protein-bound iodine
level in the serum and normal or nearly
normal uptake of radioactive iodine by the
thyroid gland.
60
consumption,10' 12, 18 the final metabolic
Cushing's disease or the treated
arthritic is the balance between this stimulation and the thyroid depression; the
rate in
latter apparently is usually the dominant.
Epinephrine produces
an
abrupt, dra-
matic rise in oxygen consumption2'4 and it
is possible that epinephrine is in part responsible for the elevation seen in the severely burned patient. At the same time,
epinephrine,
=
a
product of the adrenal
me-
CASE 47-2
:1
tia
~~~~~~~~70
50-
4'S
40/
METABOLIC RATE
35-
La
0-
z
50
*
9
30
J
40
4;4250
*
r
*PBI
48,v
5020-
o- P8
a-PBeI3
"
-"'
.,
,
IS
~~~~~~~~~~~~~~-30
UPTAKE
':
oPaI
32y
UPTAKE
1[JI
5- 27%
I.,', II_
.0
,00
DAYS POST
200
t0
4000
11
20
PTAKE
~~~~~24%
30
40
50
6O
DAYS POST BURN
BURR
FIG. 9.-Protein bound iodine and I131 uptake
determinations in 8 severely burned and one moderately burned patient. All of the protein bound
iodine measurements were within normal limits
with one exception. The earliest measurement recorded on the chart is 3.2 gamma/100 cc. and the
lower level of the normal range is 3.5 gamma. The
I131 uptakes show a somewhat greater scattering
with two determinations being below and two
above the accepted normal range of 25 to 55 per
cent uptake. There is no tendency for either an
elevation or depression of the initial I131 uptake
or PBI as the patients pass from the acute to the
healed stage of their disease.
It is difficult to believe on evidence available that the adrenal cortex could be responsible for the observed elevation of
oxygen consumption. In patients with Cushing's disease, a disorder associated with
hyperactivity of the adrenal cortex, a metabolic rate lower than normal is the rule.
The elevated adrenal cortical activity apparently suppresses slightly the function of
the tiyroid gland.7 10 Comparable suppression is induced by ACTH and Cortisone
in patients with arthritis.'7
Although there is evidence indicating
that the adrenal cortical steroids may in
themselves stimulate the rate of oxygen
FIG. 10.-(Case 47-2). Metabolic rate and thyroid function in a 23-year-old female following extensive thernal trauma. This patient shows a continuous elevation of her metabolic rate for the first
two months following trauma. Determinations
averaged plus 20 to plus 25 with peaks to plus 50
on the 12th and 33rd day after injury. Despite this
long continued elevation of metabolic rate, thyroid
function as measured by PBIs on the 3rd and 9th
day following trauma was nornal. I131 uptakes on
the 6th and 27th day after injury substantiated the
finding of normal thyroid function.
dulla, is believed to be secreted only as an
mechanism6 and presumably
therefore is released in abnormal quantities
only during the phase immediately after injury. Evidence is lacking to suggest a continuous hypersecretion of epinephrine for as
long as two months after trauma.
It is long established that the ingestion
of protein will raise the metabolic rate, the
so-called specific dynamic -action of protein.'3 Since many of the burned patients
received as much as 3000 calories containing 200 grams of protein per day in their
diet, it was felt wise to evaluate the role
played by such a diet when given over a
prolonged period. That the role of the diet
emergency
171
COPE, NARDI, QUIJANO, ROVIT, STANBURY AND WIGHT
per se is a minor one must be inferred
from the following:
The non-burned volunteer maintained a
normal metabolic rate despite the daily
high protein intake.
Patients with burns of limited extent on
a similar high protein diet failed to show
comparably elevated metabolic rates.
As the severely burned patient heals his
wounds, his appetite increases, and he partakes more willingly of the diet high in
proteins. At this time his metabolic rate,
which had previously been elevated, recedes toward normal.
The six patients with the peritonitis following the perforation of an ulcer showed
initially an elevated metabolic rate comparable to that of the burned patients, yet
they uniformly received a low protein intake. Fever, malnutrition and immobilization are other factors affecting the level of
oxygen consumption and need to be considered. Fever raises oxygen consumption
and in patients with fevers of other origins
than infected burn wounds, the rate is
raised 7 per cent for each degree (Fahrenheit) of fever.'4 In burned patients, the
fever is irregular and does not correlate
with the metabolic rate. Although fever
per se is undoubtedly a factor, it is unlikely
that it accounts for more than a small part
of the elevation encountered in the extensively burned.
Debilitated patients with emaciation and
malnutrition characteristically exhibit a
lowered metabolic rate.'4 This may be due
in part to a depression of the specific dynamic effects of their diet, but other factors
presumably play a role. All of the severely
burned patients discussed above had undergone profound protein catabolism. They all
had lost weight and exhibited the characteristic picture of low serum proteins and
anemias responding only to multiple transfusions. Yet only one, the exception, had a
lower than normal metabolic rate.
Immobilization of patients in bed may
have as one of its effects a depression of
Annals of SurgeO
February, 1953
metabolic rate. Deitrick et al, in studies on
human volunteers immobilized for periods
of six to seven weeks in plaster casts, demonstrated that the rate of oxygen consumption was decreased an average of 6.9 per
cent for the period studied.9 Patients who
have suffered extensive thermal injury may
be confined to their beds for the first few
months. Though immobilization may exert
an influence on metabolic rate, it appears
to be overshadowed by others.
CASE 49-1
,PB
+30
44y
,
+ 25
+20
+
05
iI+10I31
9.+5i
ETABOLIC RATE
UPTAKE
40%
I
-S.
lb
0
20
30
40
50
60
70
DAYS POST BURN
FIG. 11.-(Case 49-1). Metabolic rate and thyroid function in a 23-year-old female following
extensive thermal trauma. This patient is one of
the 2 showing only a moderate elevation of metabolic rate for the first 15 days after injury gradually
receding to minus 10 ten weeks after admission.
Despite the early elevation of metabolic rate, her
thyroid function as measured by I131 and PBI 5
days after injury was normal.
The patient accidentally set her dress afire and
suffered a 35 per cent burn, many areas of which
required grafting.
Last but not least, the local metabolism
in the wounds must be considered. From
the little that is known, there must be an
intense cellular and chemical activity in
the immediate vicinity of the wounds. Debris is being removed; cells are proliferating at high speed, and like embryonic tissue,
may have a high oxygen consumption. Perhaps it is this activity, multiplied quantita-
tively by the extent of the wound, which
ultimately determines the high metabolic
rate of the burned patient. In favor of this
simple, local origin in the wounds is the
correlation of the metabolic rate with the
extent of the wound area.
The factors discussed above are among
the more important influences bearing on
metabolic rate in the severely burned patient. Although seemingly diverse, they are
172
Volume 137
Number 2
THYROID FUNCTION FOLLOWING ACUTE THERMAL TRAUMA
of the effect of operation. Six patients whose
perforated ulcers were sealed surgically
were observed throughout their hospital
stay for the same reasons. The possible
cumulative effect of the specific dynamic
action of a long continued high protein diet
tion to stress.
The sequence of events and the domi- was measured in a young healthy volnant influences would appear to be as fol- unteer.
Following extensive thermal trauma the
lows: At the moment of the trauma and
immediately thereafter, there are pain and metabolic rate is elevated, plus 30 to plus
acute anxiety. Both activate the sympa- 60, for as long as two months after the inthetic nervous system: adrenalin is released. jury; it gradually recedes to normal as the
Soon infection intervenes with fever and wounds heal.
In the patients with circumscribed burns
presumably widespread changes in intermediary metabolism. Locally in the wounds, involving but 15 to 20 per cent of their
activity is intense at first with cell break- body surfaces, the metabolic rate is nordown and later with repair. Throughout mal, or only slightly elevated.
In the patients undergoing major surgical
these phases, the metabolic rate is elevated.
As wounds heal, infection regresses and procedures, the metabolic rate rose slightly
fever subsides. With mobilization of the for the first days after operation. All depatient, his appetite increases and emo- terminations, both preoperative and posttional tension is eased. During this final operative, were within normal limits.
healing phase, the metabolic rate returns
In the patients who had suffered a perto normal.
forated ulcer, the metabolic rate rose preThree things are striking. First, the ele- cipitously, as in the burned patients, imvated metabolic rate is undoubtedly related mediately after injury and operation, but
to the wasting seen in the severely burned returned promptly to normal by the fourth
patient. Second, the thyroid gland plays no to seventh days.
part in this wasting. And third, though the
The basal metabolic rate of the nonadrenal cortex is hyperactive during the
volunteer was not significantly alburned
period when the metabolic rate is elevated
tered
by the high protein diet fed him.
and its aotivity subsides to normal as the
The protein-bound iodine of the blood
metabolic rate returns to a normal level,
available evidence indicates that the hyper- serum and the thyroid uptake of a tracer
activity is coincidental rather than causal. dose of I131 was measured in eight of the
severely burned patients and one with moderate burns. The measurements, specific for
SUMMARY
thyroid function, fell within the normal
A study has been made of the metabolic range.
Some of the factors that may affect the
rates and thyroid function of patients who
have sustained thermal injury. Twelve se- metabolic rate and thyroid function followverely burned and three moderately burned ing thermal trauma are discussed.
It is concluded: that the elevated metapatients were observed from the time of
injury through healing of their wounds. bolic rate encountered in 11 severely
The metabolic rate of six patients without burned patients accounts for the wasting
burns who were undergoing major surgical such patients suffer; that the thyroid gland
procedures were observed both before and plays no part in elevating the metabolic
after operation for comparison and control rate; and that the increased activity of the
response that
we see at any one time is not the effect of
a single influence, but rather the result of
many additive and suppressive influences
affecting the human organism in its reac-
interrelated. The pattern of
173
COPE, NARDI, QUIJANO, IROVIT, STANBURY AND WICHT
adrenal cortex known to follow thermal
trauma is coincidental rather than causal.
We wish to acknowledge the help of Dr.
Douglas Riggs in guiding us through the determinations of the protein-bound iodine, of Dr.
Bengt Skanse and Dr. Alberto Houssay for carrying out some of the initial radioactive tracer studies,
of Dr. James F. Hopkirk for the studies on the
patients with the perforated ulcers, and of Miss
Halina Filipak for the metabolic rate determinations.
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