Report of Cases.

Case I. The subject was a young man, aged 22, with a neuropathic and psychopathic heredity. There was an obscure history of a head injury four years before, which probably had nothing to do with his psychopathy. Three years prior to the time I first saw him, the patient developed psychopathic symptoms and the case was diagnosed by competent authority as dementia praecox. In my opinion, the case at the time I first saw it was a typical dementia praecox.

At present, more than fifteen months after the implantation, a nodule of gland tissue about the size of a hazelnut still is perceptible at the site of the implantation. When the case was last reported there had been considerable improvement in the patient's condition. He had ceased his frequent writing of incoherent, rambling dissertations on architecture and kindred topics, and no longer complained of hearing enemies whispering criticisms adverse to him, which symptoms had been very prominent. His mother stated that he was more ambitious and energetic. At present he is attending school and appears to be getting on fairly well with his studies. He is distinctly more. vigorous than at any time since his illness began. I, of course, am not prepared to say that the improvement is due to the implantation, or to share in the enthusiasm exhibited by his family. That the improvement may be due to remission is obvious. I present the case as merely worthy of note.

Case II. This is by far the most remarkable of my entire large series of implantations, and to my mind is as conclusive evidence of the value of the work as a single case possibly could be. It is especially weighty evidence when considered in connection with the apparent results of my other implantation work.

A man, aged 29 years, sustained an injury to his testes while playing football, twelve years before he consulted me in July, 1915. His right testicle was enormously swollen (probably hematocele) and very painful. When the swelling subsided, the gland had entirely disappeared. The remaining testicle atrophied to a moderate degree. Virility was unimpaired and the patient married three years later. No children were born of the union.

About twe month prior to my examination the patient, without preceding trauma or known infection, suddenly developed pain in the left ileolumbar region, left spermatic cord, and the remaining testicle. The testicle did not swell, but, the patient stated, the veins above it were swollen. The temperature record was not available. There were no urinary symptoms. At the end of three weeks the testicle had completely atrophied, and some weeks later the case was referred to m.

On examination, I found a healthy-looking subject, over-fat, with moderately feminine secondary sex characteristics. The beard was almost negligible; the mammae moderately large, and the pelvis distinctly broader than the normal masculine type. The patient stated that his physique had shown these peculiarities increasingly since his injury, twelve years before, but that his sexual power had been "satisfactory" until after the loss of the second testicle. During all these years he had not been physically as fit as before, and for about a year he had with difficulty met the physical and mental exigencies of his business, this lack of efficiency having increased rapidly since the loss of the remaining testicle. Since the loss of the second testicle there had been complete impotency.

Examination showed scarcely a vestige of tissue at the end of the spermatic cords-nothing, indeed, that could be accepted as even a remnant of gland tissue. The penis was of only moderate development, with a long prepuce, but otherwise normal.

August 1, 1915, I implanted on this patient both testes taken from a boy of 14, dead of a crushing injury. The subject was just approaching puberty, and not well developed. The testes were removed six hours after death, and kept on ice in sterile salt solution until the operation, thirty-nine hours after the death of the donor. The implantation was made in the scrotal sac on each side, at the normal site of the testes. The glands were implanted entire, the epididymes not being removed. Healing was prompt; there was only 1 degree of transient febrile reaction, and very slight inflammatory swelling about the implanted glands. Five days afte rthe implantation I performed a circumcision. The patient returned home in two weeks. Vigorous and painful erections occurred after the eights day, and required an ice bag. Successful coitus was practiced three weeks after dismissal from the hospital. At present, seven months after operation, the patient reports that he is perfectly normal, is taking active gymnastic exercise, and has lost nearly 20 pounds of his flabby fat. Erections are vigorous and more frequent than in the average normal subject of similar age. The patient lays especial stress on his mental and physical fitness for business. The implanted testes have atrophied only moderately, and are of relatively fair size and fairly normal consistency. The epididymes are plainly distinguishable. As Dr. William T. Belfield, who courteously examined the case and questioned the patient, remarked, "The testes, while small, are as well developed and apparently as normal as in many perfectly virile men who come under our observation."

In passing I wish to state that, for a while after the implantation, the patient experienced normal orgasms emission. He

stated to Dr. Belfield and myself that after a few weeks he began to have emissions of a considerable amount of fluid, and that these emissions were almost constant. The emitted fluid, while it has not been examined, of course is not testicular secretion-no anastomosis having been done-but comes from the urethra, Cowper's glands, the prostate and the seminal vesicles. In brief, it probably is composed of all the usual normal elements of the normal semen, save the testicular secretion, of which the spermatozoa are the important element.

For some weeks after the implantation the patient complained of "frightful nervousness." As he described them, his symptoms were not unlike those produced by strychnin and similar spinal excitants. The "nervous" symptoms finally disappeared. I attributed them to the unwonted dose of hormone supplied by the implanted testes, to which the nervous system gradually became accustomed.

A feature of the foregoing case that is worthy of especial comment is the preservation of virility-until the loss of the remaining gland-after the accident of more than twelve years ago, despite the subsequent impairment of development of masculine secondary sex characteristics. It would seem that: 1. A relatively large dose of hormone is necessary to perfect development of secondary sex characteristics. 2. A very small dosage is sufficient to preserve virility. 3. Once virility is established, an extremely small dosage of sex hormone will preserve the psychosexual and physiosexual sex characteristics that are so essential to potency. It has been observed that individuals possessed of exceedingly rudimentary testes often are virile. Indeed, it has been my observation that such persons sometimes are possessed of more than the average degree of virility. I recall soveral cases of cryptorchidism coming under my observation in which there was a normal degree of virility with complete sterility. I will not enter here into an exhaustive study of the physiologic and therapeutic suggestions offered by the foregoing case, as they have been comprehensively discussed elsewhere. This much appears evident, namely, that my implantation work has passed the experimental stage. It would require a degree of skepticism which I am free to say does not inspire me at this stage of my work to attribute to psychic impress such results as have obtained, notably in the case of double implantation herewith recorded.

It will be interesting to note the further progress of the case relative to atrophy of the implanted glands. Thus far there has been less atrophy than in my other cases, in a similar length of time. Possibly the preservation of the epididymis has something to do with this. As to how long the therapeutic results will endure, one cannot predict. Possibly permanently, or at least long after the last vestige

of implanted gland tissue has disappeared. I am confident that, as long as even a small portion of the implanted tissue remains, its favorable effects will endure. Even though an occasional repetition of the implantation should prove necessary to maintain the patient's normal sex standard, the result still would be remarkable and the scientific status of the method sustained.

Case III. This case was purely experimental, and no exhaustive report will be made at this time. The subject was a healthy professional man, aged 58, who submitted himself to the experiment from purely scientific motives. The companion testis of that used in Case 2 was employed. The implantation was made in the left scrotal sac. The local result of the implantation was what I now feel justified in calling "typical," save that the subject got about on his feet after twenty-four hours, which resulted in considerable swelling and tenderness of the operated region. When the patient keeps to his bed, the reaction is very slight, compared to the tissue "insult."

In this case there was a rise of temperature of 1 degree, which subsided in twenty-four hours. Seven months after the implantation a nodule about the size of a good-sized grape is still perceptible.

Certain oddities of apparent physiologic effects were noted in this case, which, if sustained by future observation, will be reported.

Case IV. A man, aged 60, apparently normal in every respect, submitted to implantation, with the view of increasing physical vigor and endurance in general, and sexual vigor in particular. I secured the necessary material from an apparently healthy lad of 17 years of age, dead twelve hours of crushing injury to the head. Death has occurred about four hours after the injury. The operation was performed shortly after that in Case II, so that at present, over seven months have elapsed since the implantation. The testes were refrigerated for about forty-eight hours. A single gland, the right, was employed. The epididymis was removed, and numerous areas of the cortex denuded. The implantation was made in the right scrotal sac. The implantation was perfectly successful. There was practically no febrile reaction, and very little swelling at the site of the implantation. No opportunity has presented itself for a review of the case, but the patient writes that he is well satisfied with results, and that there is still "quite a lump" at the site of the implantation.

Conclusion.

Not only do I feel strengthened in my heretofore published impressions of the value of sex gland implantation, notably in the matter of increasing physical efficiency, and especially physiosexual efficiency, but also I am convinced that, when technic and material are

right, and the recipient properly selected, preservation of hormone production by the implanted gland for at least a prolonged period is certain. That permanent physiologic and therapeutic advantageous results are equally certain, I am now strongly inclined to believe. Thus far I have observed no case in which the implanted tissue had completely disappeared, or even practically so, prior to from twelve to eighteen months.

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THE NEW EDITIONS OF THE U. S. P. AND N. F.

A Review of the Pharmacopoeia of the United States of America, Ninth Decennial Revision, and of the National Formulary,

Fourth Edition.

The Pharmacopoeia of the United States of America, ninth decennial revision, and the National Formulary, fourth edition, which are decreed to be official from September 1, 1916, are now available in the ordinary channels of trade. Public health officials and others intrusted with the enforcement of pure drug laws will no doubt be interested in the nature and composition of these two books that are recognized by law as standards for drugs and preparations and which are generally used as the basis for prosecution in cases involving adulteration or the misbranding of drugs. The two books were this time published simultaneously, and for the first time in their history an effort has been made to have them in harmony as to contents and standards.

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