her attention to the bulging of her eyes, which she states, have since increased in size. By this time her symptoms had become considerably aggravated and were associated with profuse perspiration at night. Being no longer able to pursue her daily work she consulted a Christian scientist. Seeing that she was losing gradually in weight and that eddy Taken May 15. ism had no effect, a regular physician was consulted December 28, 1903. The medical attendant prescribed an ointment to be applied to the goiter and the administration of an internal remedy. Her condition under the treatment rapidly grew worse and from this time on the patient had a more or less incessant exhaustive diarrhea (8 to 10 passages daily, sometimes less). The symptoms became alarming and desperate, and her loss in weight between January and May was something appalling (46) pounds). The periods of slight mental perturbation which she previously displayed, now became more frequent and pronounced. The attacks of syncope which now manifested themselves, together with the numerous choking spells, added considerably to the gravity of her condition. Walking and climbing stairs were only possible with assistance, and at that extremely exhausting, and very slow work. The almost complete anorexia made matters very serious. brief, the physical signs and symptoms May 9 were as follows: In General condition, one of emaciation; slight mechanical dyspnea, moderate anemia, an anxious and staring expression, weight 96 pounds. Eyes: Considerable ocular protrusion, particularly the left eye; exquisite v. Graefe and Stellwag symptoms (one lid closure about every 90 seconds), Möbius symptom (internal rectus insufficiency) not present. Neck: Contour greatly altered, both thyroid lobes considerably enlarged, the enlargement of left lobe greatly in excess. A pronounced pulsation of struma was visible. Circumference 39 cm. Thorax: Lungs negative. In the precardial area a diffuse pulsation. The apex beat not circumscribed. A slight dilatation to the right and left on percussion. Auscultation revealed a blowing systolic murmur over the entire cardiac area, most pronounced at the base. No accentuation of sounds. Pulse: Wave small, though equal, regular, and rhythmic. Arterial tension diminished. Pulse-rate 165 per minute. Nervous system: Reflexes considerably increased. A fine oscillatory motion of the fingers when abducted. (Marie symptom.) pronounced choreiform movements of upper extremities. No disturbance in sensation. Vasomotor disturbances: The entire body presented a moist condition. Vigoureux symptom positive. (Increased electric conductibility of the skin, due to increased moisture.) Urine not catheterized; specific gravity, 1016 reaction acid, a trace of nucleoalbumin and serum albumin; indican not increased. Sugar, acetone, diacetic acid, peptones, etc., absent. An alimentary glycosuria upon the Taken August 1. administration of 50 grams of grape sugar. Stools: Consisted of watery discharges. Blood: Erythrocytes, 4,760,000 per cmm.; leukocytes, 3,760 per cmm. (Türck modification); hemoglobin, 65% (Fleischl-Miescher with control). Stained specimen one of oligochromemia with a relative increase in lymphocytes. The hematologic findings are the true picture of a chlorosis. The essential 1 changes: Between May 9 and 16, large doses of bromids were given internally without effect. Loss in weight during this period, 2 pounds (weight 94 pounds). Pulse, 160. May 16.-Thyroidectomized goat's milk used (3 pints daily). Other medicines discontinued. May 27.-Condition improved. Patient less excited, diarrhea somewhat decreased, appetite improved, no choking spells. Weight increased 4 pounds (98 pounds). Pulse, 135. June 3.-Condition considerably worse. Patient received only one quart of milk the entire previous week. Diarrhea very severe, frequent attacks of choking spells. Weight decreased 2 pounds (96 pounds). Pulse, 155. June 10.-Condition better. Diarrhea less severe, appetite good, sleeps well, less excitable. Weight increased 3 pounds (99 pounds). Pulse, 130. Exophthalmos and goiter unchanged. June 20.Condition greatly improved. Patient able to indulge in moderate exercise without fatigue. Diarrhea has disappeared, tremor considerably lessened. Choreic movements have almost entirely disappeared. Appetite, sleep. etc., good. Weight increased 4 pounds (103 pounds). Pulse, 125. Neck 38 cm., exophtalmos conspicuously less. June 27.-No more diarrhea, no choking spells. No complaints of any kind. Weight increased 2 pounds (105 pounds). Pulse 120. July 5.Fully able to do all kinds of domestic work. No complaints whatsoever. Weight increased 1 pound (106 pounds). Pulse 125. July 11. -Condition excellent. Weight increased 2 pounds (108 pounds). Pulse 130. July 23. -On the day previous to her visit she had diarrhea, which lasted 12 hours (probably due to an error in diet). Weight increased 1 pound (109 pounds). Pulse 115. August 1. -Weight increased a half pound (1093 pounds). Pulse 118. Neck 36. A return of A return of the menses during this week. Hemoglobin, 60%. Leucocytes, 4,080 per cmm. Discussion.It is not my purpose to discuss all the symptoms presented in this case, as the majority of them are thoroughly considered in almost every textbook. Of interest, and worthy of mention, however, is the great disproportion of the ocular protrusion and enlargement of the lobe of the goiter on the left side with the corresponding side, as the photograph of May 15, clearly indicates. The two symptoms deserving a passing consideration are the choreiform movements and the leukopenia. The choreic twitchings, frequently occurring in Graves' disease, have prompted some writers (Fry, Sutherland and others) to suggest a possible relation between exophthalmic goiter and Sydenham's chorea. I do not dispute the possibility of a coexistence of both maladies in the same individual, and it is true that an exophthalmos may occur in chorea, but considering the prominent eyeballs of many normal individuals, and that a pronounced exophthalmos may occur in other affections, particularly chlorosis, I do not believe one is any more justified in suggesting a sort of relation between chorea and Graves' disease, simply because a common symptom or so may occur in both affections, than between true diabetes and exophthalmic goiter, because of the presence of glycosuria. Doubtless, the choreic movements have a similar origin in both Graves' disease and chorea, that is, cortical irritation, the one probably the products of the thyroid gland and the other, according to many authorities, an infectious agent. A leukopenia has been frequently observed in Basedow's disease, and it is possible that the toxic properties of the thyroid gland have a negative chemotactic action on the hematopoietic organs. The case in question shows a leukopenia of 3,760 per cmm., but the case is objectionable on the ground that the patient is chlorotic. The associated chlorosis, I believe, can only be regarded as coincident, but the coincidence is sufficient to hinder the drawing of conclusions as to what effect the hyperthyroidism had on the blood impoverishment. It would seem, however, that the thyroiodin, or possibly other toxic substances of the thyroid gland affected the blood-forming organs but little as the hematologic pictures remained practically unchanged (August 1 leukocytes 4080 per cmm. hemoglobin 60%) whereas all the other symptoms improved decidedly. However sceptical one may be regarding the proficiency of the milk treatment in exophthalmic goiter, it cannot be denied that this report is another striking evidence testifying to its merits. In looking over the case one cannot help but admit the severity of its type. The fact that since January the symptoms ran an alarming course together with a loss in weight of 46 pounds in less than 43 months or more than 10 pounds per month and a pulse-rate of 165 beats per minute would indicate the inevitable termination. Surgical interference was beyond the question, as death would have certainly supervened through cardiac failure. Considering the history it is not at all improbable that the patient's rapid decline from January to May might have resulted from the promiscuous use of iodin or its preparation, which the patient's previous medical attendant may have employed, as she states her condition became daily more aggravated during his treatment. The comparative photographs sufficiently illustrate the improvement in her fa cial expression and the exophthalmos. The essential change in the goiter consists chiefly in a reduction of the left lobe, as the illustration clearly shows. The total difference in the measurement of the neck between May 9 and August 1 was 3 cm. Regarding her pulse and weight, it is to be observed the one gradually decreased and the latter increased. It is interesting to note that during the week of May 27 and June 3 the patient received only a small quantity of the milk, resulting in a loss of 2 pounds in weight, and the pulse-rate increased from 135 to 155 per minute. The diarrhea, increased excitability, choking sensations, etc. (the latter probably also dependent on toxic effects, as the goiter remained unchanged), also returned. From June 3, three pints of milk were daily and regularly given, with a gradual increase in eight to 1093 pounds on August 1, or a total of 13 pounds during these two months. During the same period the pulse-rate also decreased from 155 to 115 per minute, and her general condition improved to such an extent as to permit her to indulge in her ordinary walks of life. During the last week of July her long ceased menstrual flow (two years) again reappeared, and in the past six weeks her only reply regarding her condition was, "I feel perfectly splendid." still continues to take the milk regularly, as I am convinced were it to be discontinued it would only bo a question of time ere she would lapse into her former condition. The milk, therefore, cannot be regarded as a curative agent. She I cannot agree with Goebel, who regards the milk as directly affecting the thyroid gland, limiting its production of thyroiodin and possibly other toxic substances which the gland may secrete. The theory of Lanz is the more plausible, but instead of the milk having a direct antagonistic action I am inclined to believe it is more of a process of neutralization or possibly combination and the effects only last as long as the milk is given, which the case in question uniquely illustrated during the period in which the patient received but a small quantity of milk. It is also my conviction that the severer the exophthalmic goiter, the more milk is required to neutralize. To this fact I attribute the brilliancy of the result over some of the other reported cases, as the patient received three pints of the milk daily, a larger quantity than in the majority of those reported. The rapid in crease in weight was certainly not due to the nutritive qualities of the milk, although I admit its value as a nutritious aliment. but considering that the patient daily took large quantities of cow's milk constantly during her illness without the slightest beneficial effect, it is safe to assume the increase was due to the therapeutic action of the milk. The assumption too, is well founded, as the individual's increase in weight during the first half of the treatment was 12 pounds, whereas from July to August the gain was only 3 pounds, notwithstanding the fact that the same quantity of milk had been given. I would suggest the use of dessicated thyroidectomized milk in the form of tablets, as preferable to that in its natural state. In concluding this paper, I do not wish to be construed, as saying that in the milk treatment we have found a specific in Basedow's disease, as time alone can determine its value. My case, an unobjectionable one, only adds to its merits, and the brilliant result yielded by the milk is cerainly inspiring and worthy of further pursuit. I am deeply indebted to Dr. Earls for his kindness in permitting the use of Trinity Hospital, and Drs. C. H. Lemon and E. J. Purtell, for having thyroidectomized the goat. Parke, Davis & Co. are supplying me with capsules of desicatted thyroidectomized cow's milk, with which I am at present experimenting. 11 Rev. Med. de la Suisse, No. 5, 1899, p. 301. 12 Ibid, p 618. 13 Revue Neurol.. January 30, 1902. 14 Lancet, August 26, 1899. 15 Medical Record, December 2, 1899. 16 Deutsche med. Wochenschrift, Nr. 38, 1899. 17 Neurolog. Centralb., Nr. 4, 1903. 18 Munchener med. Wochenschrift, Nr. 4, 1903. 19 Ibid, Nr. 20, 1902. 20 Correspondenzbl. f. Schweitz. Arzte, Nr. 23, 1899. 23 Therapie der Gegenwart. August, 1903. DR. CHAS. A. L. REED, of Cincinnati, has been appointed by President Roosevelt as one of the two members from the United States to the joint commission which is to settle the dispute between the United States and the Republic of Panama over certain property rights. The commnission will work in conjunction with a like number appointed by the Panama government and the British Consul. Their duties will be to appraise private property in the canal zone which is to be used in the construction of the canal. GONORRHEA IN THE MALE.* M. E. SILVER, M. D. SIOUX CITY, IA. THE importance of this subject is fully realized when we consider the great number of victims this disease claims as its own daily, in every class or condition, and the tremendous state of ignorance that exists with the laity as to the true infectious nature of this disorder, either to other parts of their own body, or that of transmitting it to others, of. ten those nearest and dearest to them; and the indifference, I fear, oft displayed, even among some of our profession who are much inclined to look very carelessly on a case of gonorrhea, and instead of giving the matter their most earnest attention and pointing out to the patient the importance of this disease with its possible complications, they but too hastily write a prescription for internal medicine and injection for the patient to use it himself, with what results only luck can tell. The time allotted for a paper however, only makes it possible for me to touch very lightly on some of the paramount points connected with this disorder, and in a manner I only open the discussion. Gonorrhea is undoubtedly one of the earliest afflictions of mankind, which was classified by early writers as a filth-disease, along with syphilis and chancroid. It was not until 1879, when Neisser of Breslau first pointed out to us the organism-the gonococciwhich is its specific cause. Of course, he like other discoverers of certain truths, had to contend with opposition that in some minds is rooted even to this day. But Neisser's discovery was soon confirmed by other leading observers, and it is true that at the present time all the scientific physicians uphold Neisser in spite of the fact that the gonococci organisms are often found in the healthy urethra. As to the Origin of the Gonococci Organisms. Bumm, of Basel, who has given the subject a great deal of study, has some interesting conclusions on the origin of the gonococcus, claiming that like all other microorganisms in their evolution have acquired specific functions, and that sooner or later by modified culture methods, it may be possible to rob this organism of its specific character and make it a simple non-specific pus producer. While this may be hoped for in the laboratory, it is a fact nevertheless, that in the human being it does not hold true, for a most virulent attack may be brought on in a virgin case from an apparently mild sufferer. In its artificial propagation the gonococci is *Read before the Sioux Valley Medical Society. very capricious, requiring the greatest care as to the proper culture media, etc., but in the genito-urinary tract it thrives most luxuriantly. Bumm further declares that gonorrhea is essentially a disease of the epithelial layer and does not pass beyond the boundary. In the incubative stage the moment the gonococci are deposited upon the mucosa, they begin to multiply with their characteristic rapidity and adhere very closely to their primary location. In their further growth they begin to penetrate between the epithelial layers which at once excites a remarkable transmigration of leucocytes to the irritated areas, and as the disease progresses the epithelium becomes more or less disorganized, in some places being lifted up from its base, in others cast off in large flakes, at this stage myriads of leucocytes are found beneath the epithelium and upon the surface is a copious. purulent discharge. As the epithelium is shed the gonococci begin rapidly to disappear, for their further pentration in the tissues is limited by the substratum of connective tissue; this explains why some cases of gonorrhea are selflimited, treatment, or no treatment. Gonorrhea in the male never originates "de novo," but is always communicated to him and the urethra is the most frequent seat of infection, although the eyes and rectum may be the first parts attacked. Gonorrhea, too, differs from many other diseases in the fact that one attack does not bring immunity against any future attacks. The persistence of the gonococci organisms in individuals once infected is remarkable from the fact that it may never be totally eradicated, and I would even modify Ricord's statement that "Anyone can tell when a gonorrhea begins, but God alone knows when it will end," to, "Anyone can tell where a gonorrhea begins, but God alone knows where it will end. This is getting to be more recognized of late, since the microscope in the hands of careful observers has been able to demonstrate complications following an attack of gonorrhea never before thought of. Gonorrhea is a serious and often dangerous disease. since it does not always remain limited to the primary focus of infection, but progressively may invade nearly all other parts of the body. It is this fact that has led some to declare that gonorrhea is frequently a more dangerous disease than syphilis. One more truth about the infection of gonorrhea is this: that whilst a certain couple may have been thoroughly cured of this affliction as far as being capable of reinfecting each other, let a third person come in intimate contact with each one of these, a most violent infec tion may follow such an act in the third party. Thus we have in the wake of an acute anterior urethritis a great many complications, the cause of which is yet really unknown, as the best authorities differ on this head. The questions arising, are some of the complications to be attributed to the fact that the organisms themselves succeed in being disseminated through the blood stream, or it is due to the toxins which they generate? Again, it is possible for the organism to thrive outside of the mucous surfaces provided with cylindrical epithelium or epithelium transformed in this variety as held by Baum and Baumgarten? Or is it all due to a mild pyemia or is it simply through continuity of stricture from the site of original infection? Not having solved these problems fully, who can tell what the limit of complications may be of a given case, or what influences the gonococci or their toxins may have over other organisms like the tubercular organisms, especially in the genito-urinary tract? COMPLICATIONS OF GONORRHEA. The complications of gonorrhea nay in some cases be nil. In others so slight that it escapes the ordinary attention of either patient or physician. In others, again, of the most violent forms. Of the complications recognized for many years and mentioned in all text-books we have: Epididymitis; prostatitis; cowperitis; folliculitis and periurethral abscess; lym. phangitis and lympho-adenitis; phimosis and paraphimosis; balanitis and balanoposthitis; cystitis, ureteritis and pyelitis; gonorrhealconjunctivitis; gonorrheal rheumatism; proctitis; besides, posterior urethritis, chronic urethritis and stricture. The following complications are just of late. being credited to gonorrhea, namely: disturbances referable to the nervous system; spinal irritation associated with sensory and motor symptoms; myelitis; cerebro-spinal meningitis in which on lumbar puncture were found gonococci; peritonitis; endocarditis and phlebitis which may have as a further complication cerberal embolism with hemiplegia and aphasia; percarditis; affections of the pleura and gonorrheal myostitis as demonstrated microscopically by Ware and as reported in Vol. I. series 12 of International Clinics with demonstrations of microscopical specimens. TREATMENT OF GONORRHEA. When attempting to make some remarks on the treatment of gonorrhea, I am well aware of the fact that I enter on a path full of con fusion and uncertainty, for it must be admitted that as yet we have no specific that is warranted to cure Who knows if in certain cases a sufferer would not be better off if we did not use any or all of the many drugs that are considered so excellent from the standpoint of the pharmaceutical manufacturer? Much, however, can be done by the physician towards the prevention of possible complications, and, what is even more important, from the sociological standpoint, to check the possible spread of the disease to healthy people. Before outlining any course of treatment, we should not forget that many cases with a urethral discharge are not gonorrheal patients, and we must be careful not to convert a simple urethritis to a specific form, from the use of any instrument or syringe laden with gonococci from a specific case. Having fully convinced ourselves by microscopic examination that the given case is a specific one, the following three course of treatment are before us: (1) Hygienic. (2) Internal treatment. (3) Local treatment. And the first two I consider the most important. Under hygienic I would embrace the following: (1) Acquaint your patient with the fact that gonorrhea is far from being in every instance a mild disease, and that you must have all his assistance to prevent any possible complications, which so often do arise, and especially dwell on the possibility of his spreading it to his eyes. (2) Advise all the rest possible for the patient, even to bed if necessary, at any rate, prohibit heavy lifting, dancing, or too much standing on his feet. (3) Food should consist of the lightest forms-milk to be the chief article of diet, and the total avoidance of all acids in the form of pickles, vinegar, salads, etc. (4) No sexual excitement, either active or passive, from the beginning until at least two months after a thorough eradication of symptors, etc. (5) Cleanliness within and without in the most liberal form. (6) A suspensory bandage for its aid in the prevention of orchitis. |