488 EMIL GOETSCH 



Benedict has criticized the method of predicting the heat production 

 from the unit of surface area. In practical clinical work, however, the 

 determinations of the basal metabolic rate, using the standard of Du 

 Bois, have been found satisfactory. 



The method of direct and indirect calorimetry were found to agree 

 very closely when one considers the technical difficulties. The method 

 of direct calorimetry gave results which were slightly lower than the 

 indirect, the total difference being 2.9 per cent. This and the absence 

 of abnormal respiratory quotients show that the law of conservation of 

 energy holds good in exophthalmic goiter, and that there is no profound 

 disturbance of the intermediary metabolism. 



One small cretin 36 years old produced about half the calories elimi- 

 nated by children of his size. As estimated by the surface area, his 

 metabolism was about 20 per cent below the normal adult level. Three 

 and a half days of treatment with thyroid extract raised his heat pro- 

 duction to normal. 



Means and Aub (a) (b) (c) have made an extensive study of exoph- 

 thalmic goiter from the point of view of the basal metabolism. A prelim- 

 inary outline of their work was made in 1917, to be followed in 1919 by 

 two papers, the first giving their results in a study of basal metabolism in 

 hypothyroidism, and the second giving their final results in a study of 

 exophthalmic goiter. They used the level of heat production as an index 

 of the effect of medical treatment. 



Since the metabolism in hyperthyroidism was found to be consider- 

 ably above normal, then one should find in cured cases of Basedow's 

 disease rates approaching the normal. This was found by Magnus-Levy 

 to be true in two cases observed as early as 1895 and has been abundantly 

 confirmed since. When the metabolic rate is high the risk of operation 

 is considerably greater and preliminary treatment with Rontgen-rays was 

 therefore" recommended by Means and Aub (c). Similarly, other measures 

 for preliminary reduction of thyroid activity and of the metabolic rate, 

 therefore, have been used, particularly ligation of the thyroid arteries. 

 Although in three out of four cases Du Bois found an increase in metab- 

 olism, this has not been the rule. On the contrary, one generally finds 

 an improvement in the clinical condition and a fall in the metabolic 

 rate (Sandiford, 1920). After thyroidectomy, usually though not al- 

 ways, a gradual fall of the metabolic rate coincident with the clinical 

 improvement is observed. Means and Aub (c) used the metabolic rate as 

 an index to the improvement after various forms of therapy, and stated 

 that the results after Rontgen-ray treatment after two to three years 

 were as good as with surgery and recommended this treatment as a 

 preoperative measure. 



irv]x)tliyroi(lisin shows a decreased metabolism (Magnus-Levy (&), 

 ISO 5). On Bois found, as stated above, in a small cretin 3fi vears old that 



