106 THE INTERNAL SECRETIONS—1920 
legs edematous up to the knee; hands edematous; heart 
enlarged to the left, no murmurs; abdomen large and 
pendulous; skin dry; eyes and ears negative. 
Laboratory examination: No evidence of nephritis 
by special examination. Urine, 1975 c.c. in 24 hours; 
sp.gr., 1020 to 1023, trace of albumen and moderate 
number of hyalin and granular casts. 
Subsequent course under organotherapy of 3 grains 
of thyroid and 5 grains of ovarian substance (ovarian 
gland was given because commercial testicular extracts 
have, in our experience, not been effective), and later 
reductions in the thyroid dosage showed at the end of 
six months a loss of 38 lbs. in wight. Blood pressure, 
147 mm. systolic; edema, itching and headaches, as well 
as double vision, gone. A course of four grains of pitui- 
tary gland substance three times daily for four days 
brought a prompt return of the double vision. 
DIAGNOSTIC CONSIDERATIONS 
The differential diagnosis of the ovarian complex 
is not difficult. Static conditions, such as flat feet, 
lacerated perineum, etc., must be eliminated as a cause 
of backache, and the general complaint of weakness 
must not be attributed to neurasthenia, whatever that 
term may mean. 
A carefully-taken history is essential and a careful 
search for evidence of loss of secondary sexual charac- 
teristics, i. e., development of hirsuties, is essential. 
The thyroid group present a difficulty in diagnosis, in 
that the condition of chronic nephritis is very closely 
simulated. This difficulty may be eliminated either by 
the special tests which have been mentioned, i. e., the 
Mosenthal test and blood chemistry, or they may be 
eliminated by therapeutic tests, i. e., treating the case 
as if it were an endocrine deficiency, and if no improve- 
ment occurs changing the diagnosis to a chronic ne- 
phritis. 
