BASEDOW'S DISEASE 77 



acts in increasing the metabolism has been much discussed. The tremor 

 alone is not responsible for it, for after exclusion of the tremor by hyoscine 

 the exchange is not essentially reduced (Magnus-Levy). This author be- 

 lieves in a raising of the exchange in the resting cells. Andersson and Berg- 

 man have contradicted this, as after large doses of iodothyrin and thyroidin 

 they found no increase after complete relaxation of the muscles and during 

 sleep. These experiments however do not show very much, because, as 

 previously mentioned, many normal individuals behave refractorily to the 

 administration of thyroid gland. To my mind, we should not leave uncon- 

 sidered in the explanation of the increase of the fundamental exchange the 

 violent increase of tonus of the whole vegetative nervous system and the 

 heightened activity of the organs affected by it. The increase of the caloric 

 production cannot alone constitute the cause of the emaciation, but there 

 must be added to it a disturbance in the regulatory mechanism that governs 

 the taking up of nutrition. Here come into consideration especially the 

 disturbances of the stomach and intestines. I refer to what I have said on 

 this subject in the first chapter. 



In Basedow's disease also the protein exchange is increased, that is, the 

 individuals affected need more protein or more oxygen-free energy especially 

 in the form of protein-sparing carbohydrates to maintain themselves in 

 nitrogen equilibrium. In the accounting of the equilibrium we must con- 

 sider also the N-loss on account of profuse sweats. Hirschlaff estimates it 

 as 2-4 gm. in twenty-four hours. As is the case with all the other Basedow's 

 symptoms, the increase of the protein exchange may show great variations. 



The increase of the protein exchange is shown very prettily in the ex- 

 periments of Rudinger. In a nearly N-free diet, rich in carbohydrates and 

 fats (according to Lander green), in normal human beings, the nitrogen in- the 

 urine falls rapidly to 4-5 gm. a day. In Basedow's patients, Rudinger found 

 7-8 gm. N. on the fourth day. The increase of the protein exchange may 

 also be demonstrated experimentally by the feeding with thyroid-gland sub- 

 stance. Bleibtreu and Wendelstadt saw after administration of thyroid-gland 

 tablets in human beings a negative N-equilibrium that could be raised 

 by the addition of butter and sugar. Since the time of Bleibtreu and 

 W endelstadt" 1 s experiments, many investigations have been carried out 

 that show the raise in the protein exchange through thyroid medication 

 (Mayerle). In an experiment of Matthes there was shown after strumectomy, 

 with the patient on the same diet, an improvement of a previously negative 

 N-equilibrium. On the administration of dried goiter, the excretion of ni- 

 trogen rose again. Also in animal experimentation could be demonstrated a 

 rise of the protein exchange (Fritz Voit). This was shown plainest in in- 

 vestigation of the metabolism during fasting (Eppinger,Falta, and Rudinger}. 



The question whether in hyperthyroidism the increase of the protein 

 exchange is primary or only the result of an increased carbohydrate and fat 



