also reported a case of leukemia successfully treated with bone-marrow. Bone-marrow, in conjunction with splenic tissue, has also been successfully employed in the treatment of malarial cachexia.15

Having observed spontaneous disappearance of the symptoms of exophthalmic goiter in a case complicated by the development of splenitis-probably of traumatic origin-and the formation of a splenic abscess, subsequently evacuated, Wood was led to employ hypodermically a glycerin extract of beefspleen in the treatment of a later case of exophthalmic goiter, with results that were in every way gratifying.

16

For a long time, physiologists have realized the fatality of total extirpation of the pancreas, and pathologists had early observed changes in the pancreas in fatal cases of diabetes, examined after death. It is, however, only within recent years that experimental removal of the pancreas has succeeded without immediate death; and under these circumstances glycosuria, polyuria and wasting invariably developed. Here, again, it was found that if a portion of the gland were permitted to remain or were grafted in a new situation, the symptoms failed to appear. Pancreatic preparations have been employed in the treatment of a number of cases of diabetes in the hands of different investigators, with resulting improvement in some

cases.

It is the consensus of opinion that the symptoms of Addison's disease are dependent upon changes in the suprarenal bodies; and in conformity with this view a number of clinicians have employed suprarenal extracts in the treatment of that disease.17 Oliver, who, in conjunction with Schäfer, has made a study of the physiologic action of suprarenal extract, recommends its use also in cases attended with loss of vasomotor tone, in exophthalmic goiter, in cyclic albuminuria, in diabetes insipidus and diabetes mellitus, and in cases of capillary hemorrhage. In cases of anemia

15 Critzmann: Presse Medicale, 1895, No. 68, p. 507. 16 University Medical Magazine, February, 1895, p. 313. 17 Shoemaker and Wood: University Medical Magazine, February, 1895, p. 309. Rolleston: British Medical Journal, April 16, 1895, p. 745. Jones: British Medical Journal, August 24, 1895, p. 482. Oliver: British Medical Journal, August 31, 1895, p. 561. Sansom: British Medical Journal, November 16, 1895, p. 1235. Osler: International Medical Magazine, February, 1896, p. 3.

thus treated, he has observed a rapid rise in the percentage of hemoglobin.16

In a case under my observation, presenting Addisonian symptoms, appreciable benefit followed the use of such an extract. Post-mortem examination, however, failed to disclose distinctive changes in the suprarenal gland.

It has been shown experimentally that the symptoms resulting from removal of the pituitary body-lowering of temperature, anorexia, lassitude, convulsive movements and dyspnea-can be prevented by injections of pituitary extract. In some cases of akromegaly relief has followed employment of a similar extract. 19 In the discussion following the report of a case of akromegaly that it was my privilege to make to this Society in 189520 I took occasion to refer to the possible utility of a preparation of the pituitary body in the treatment of that disorder.21 In accordance with this thought Mess. Armour and Co., of Chicago, at my request kindly prepared for me such an extract (of which one part of the desiccated product represented seven parts of crude pituitary body) of which I began the administration of one grain thrice daily, but the patient did not remain long enough under observation and no therapeutic effect was noted. At about the same period or a little later Marinesco reported to the Société Médicale des Hopitaux three cases of akromegaly treated with pituitary extract in which symptomatic improvement resulted. Bramwell and Murray" have employed thyroid extract in the treatment of akromegaly, but without pronounced effect.

22

Actuated by the results secured in the treatment of goiter with thyroid extract Reinert" was led to employ the prostate gland of steers in the treatment of four cases of prostatic hypertrophy, in two of which reduction in the size of the enlarged gland was noted. If these observations be correct the va

18 British Medical Journal, September 14, 1895, p. 683. Pulse-Gauging, London, 1895.

19 Caton: Lancet, February 9, 1895, p. 349.

20 Transactions of the Philadelphia County Medical Society, 1895, xvi, p. 308.

21 Loc. Cit., p. 314.

22 Mercredi Medical, 1895, No. 46, p. 550.

23 Atlas of Clinical Medicine, vol. ii, p. 3.

24 British Medical Journal, February 9, 1895, p. 293.

25 Centralblatt fur die Krankheiten der Harn- und SexualOrgane, B. vi, H. 8, p. 393.

lidity of the fact cannot be negatived by a priori considerations; although one would naturally look for therapeutic effects from prostatic administration in the presence of symptoms attributable to loss of function of the prostate in consequence of surgical removal or of disease. A parallel statement may be made concerning the employment of testicular extracts. At the same time it is not necessary to deny that from their nature all organic extracts may possess stimulating properties.

The most recent development in the domain of organotherapy consists in the employment of preparations of the ovaries of animals in the treatment of the symptoms resulting from removal of the functional influence of the ovaries in women either at the natural menopause or at that induced artifically by surgical intervention or by disease-processes. Observations upon these lines seem to have been made almost simultaneously and independently by Mainzer and by Chrobak in conjunction with Knauer. To the former belongs the credit of priority of announcement who reports a case in which relief of symptoms followed use of an ovarian extract. Chrobak" had independently conceived the idea that the distressing symptoms so often observed after ovariectomy could be prevented by permitting to re

main a portion of ovarian tissue and that they could be relieved when present either by ovarian grafting or by internal administration of some preparation of the ovary. tion of the ovary. Acting upon this thought he has of late years in operations upon the uterus and ovaries made a practice whenever possible of leaving behind a portion of ovarian tissue. He has,besides, during the past year employed an ovarian extract in a number of cases in which the ovaries had previously been removed and in one with normal genitalia in which profound climacteric symptoms were present. The results, so far as they could be analyzed, were satisfactory and encouraging. The experiments of Knauer,28 undertaken at the suggestion of Chrobak, show not only that the ovaries are susceptible of successful transplantation, but also that they are capable of functional activity in their new situation.

In the foregoing account I have not attempted to enter upon an exhaustive consideration of the whole subject of organotherapy, but have have endeavored merely to illuminate some of its more practical aspects. There is much yet to learn, perhaps not a little also to unlearn, but a good deal of what has been accomplished will permanently endure; while the outlook for the future is hopeful and encouraging.

The following case is deemed worthy of report on account of the important diagnostic and therapeutic problems which it presents for solution.

A. M., a female, fifty-four years of age, presented herself at the skin, department of the Polyclinic Hospital, on the twenty-sixth of May, 1896, with multiple gummata of the tongue and a

26 Munchener Medicinische Wochenschrift, 1896, No. 12, p. 188. 27 Centralblatt fur Gynakologie, 1896, No. 20, p. 521. * Read before the Philadelphia County Medical Society, June 24, 1896.

tubercular syphiloderm of the face. She was ordered potassium iodid in fivegrain doses, to be taken thrice daily. The patient took the first dose on the evening of the same day. On the following morning, she experienced symptoms of conjunctival irritation, and at the same time some tenderness of the gums. Six days later, she again presented herself at the clinic. At this time the following phenomena were observed: The conjunctivæ were intensely 28 Centralblatt fur Gynakologie, 1896, No. 20, p. 524.

injected up to the corneal margin; there was a serous nasal discharge; the patient complained of frontal and malar pain; the saliva dribbled from the mouth; the breath was offensive; the gums were eroded, spongy and bleeding; there was distinct ulceration along the dento-gingival border, especially of the canine teeth. The iodid was continued in the same dose, and the patient was seen three days later. The stomatitis was somewhat improved; the conjunctivitis remained unchanged; the lesions upon the tongue and face were undergoing rapid involution. The dose of the drug was then reduced to two grains thrice daily, and an eye-lotion and mouthwash ordered. From this time on, both the mouth and the eyes improved. At the present time, the conjunctivitis is well. The gums are still slightly congested and denuded of epithelium, but the fetor and the salivation have disappeared. The prescription was pounded at the pharmacy of the hospital, and the apothecary was emphatic in his asseverations concerning its accuracy.

com

The patient was questioned as to the antecedent ingestion of mercury. She is a woman of fair intelligence and apparently has a good memory. She stated that she had taken no drugs for two or three years, with the exception of one bottle of a patent medicine, which she took about six months ago. She was subjected to repeated interrogation, but adhered to this statement. This information is essential to a proper consideration of the case, inasmuch as the stomatitis had all the features of the classic "stomatitis mercurialis." In fact, those who observed the case were inclined to the belief that the potassium iodid had simply set free hitherto insoluble mercurials which had been deposited in the various tissues. This eliminative action of the iodids has, however, been recently challenged.

Dr. J. William White, in his admirable article on the treatment of syphilis, in Morrow's "System of Genito-Urinary Diseases," says, "the observations of Melsens and Guillot, long quoted in support of this view (namely, that the iodids do good in syphilis by eliminating the mercury), have recently been contradicted by Suchoff, who asserts that the administration of the iodids

really retards the elimination of mercury." Whether this be true or not, it matters not. The history of the case under discussion strongly militates against the view that the stomatitis is due to mercury eliminated by the iodid. Schuster has proved that all mercury is entirely removed from the system six months after its ingestion, even though a long course be taken. The patient took but one bottle of an unknown mixture six months ago, and prior to that time nothing for two years. It is extremely improbable that sufficient mercury could have been in the system to have produced the result narrated. We may, therefore, reasonably exclude mercury as an etiologic fac

tor.

In studying the subject of iodism, one is struck by the fact that the iodids. seem to be capable of setting up inflammations of almost any mucous membrane. Conjunctivitis, rhinitis, pharyngitis, laryngitis with edema, and bronchitis may all be produced by their administration. From a priori reasoning, therefore, it would not seem at all strange if the same drug were capable of producing a stomatitis. Lauder Brunton, Rilliet and other authors, indeed, do mention salivation among the rarer toxic effects of the iodids. It is to be deplored that the terms salivation and stomatitis are at the present time used indiscriminately. Salivation means merely an increased flow of saliva, a sialorrhea. We take it that the authors quoted refer merely to this functional change.

Bumstead and Taylor state that "salivation sometimes occurs after the use of the iodids, but is never so severe as that occasioned by mercury, nor is it ever attended by ulceration like the latter."

Fournier, in his incomparable work, "La Traitement de la Syphilis," says, "the iodids excite at times a certain degree of salivation. This salivation does not at all resemble that of mercury. It has neither the abundance, the odor nor the inflammatory phenomena. It is a cold sialorrhea, if I may use the expression, with absolute integrity of the mouth. It is at most comparable to the sialorrhea of pregnancy.'

This is certainly a most formidable

array of opinion against the supposition that the iodids may produce a stomatitis such as the one in question. Nevertheless, Kaposi, one of the foremost German syphilographers, says that "the iodids may, in rare cases, cause a gingivitis and stomatitis." With these facts in mind, the following propositions are tentatively suggested:

Sialorrhea is the first stage of mercurial stomatitis.

The iodids are freely eliminated by the salivary glands.

In some cases they may produce sialorrhea or salivation.

In extremely susceptible individuals, gingivitis and stomatitis have been produced (Kaposi).

The possibility of mercurial stomatitis has been firmly eliminated.

This leads us to the expression of the opinion that the stomatitis reported was due to the administration of potassium iodid. This view is confirmed by the coincident appearance of the stomatitis with the other symptoms of iodism. After five grains of the drug had been taken, conjunctival irritation and tenderness of the gums manifested themselves synchronously. If potassium iodid can produce a sialorrhea, it may, in more susceptible cases, produce a stomatitis which, in still more susceptible individuals, may go on to ulceration. In other words, we may have as a result of the administration of potassium iodide a stomatitis which differs in no respect from stomatitis mercurialis.

About three years ago I conceived the thought that the ideal method of doing intestinal approximation would be endto-end union by means of a collapsible bobbin, which could be removed from a small slit in the bowel beyond the point of anastomosis. In 1893 Charles Lentz & Sons attempted to make for me such a bobbin out of metal. During the past winter I had them at work upon a bobbin of spring wire, ballooning, with a central constriction, and after use collapsing under pressure and lengthening

into a

narrow removable cylinder. While perfecting this instrument it occurred to me that an inflatable rubber bag or bobbin of the proper shape would be just the thing. I immediately sent diagrams and dimensions to the Davol Rubber Co., who promptly made me three sample bobbins, alike except in size. One of these I used in my first experiment on the dog. These were very similar to the Barnes uterine dilators. I subsequently improved the bobbin by having a central band one-sixteenth of an inch wide, which thickened and preserved under distention the con

Presented to the Philadelphia County Medical Society, June 24, 1896.

stricted part between the spherical ends. These bobbins-I have not decided on a better name-which we will call No.1, are intended strictly for end-to-end anastomosis. They differ only in width. The bobbins proper are two and one-half inches long with a tube-extension at one end through which the cavity can be filled. The spherical ends, both alike collapsed, measure from one to two inches, increasing by a quarter of an inch for the different sizes. The diameter of the collapsed bobbins at the constricted portion is three-eighths of an inch less than at the center of the spherical ends.

My next bobbin, which we will call No. 2, differs only from No. 1 in that the spherical ends are of unequal dimensions. Its use is to unite hollow viscus, such as the stomach, or a section of large bowel with intestine of narrower caliber. Hence it can be used in pylorectomy, gastro-enterostomy, and ileo-colostomy.

one-fourth to less than half an inch. The end of the filling tube of the bobbin is brought out of the bowel through this slit, the bobbin is gently emptied and removed, and the small incision closed by a few sutures.

My next bobbin, No. 3, is for lateral anastomosis. In this the filling tube enters the bag at its constricted portion. The bobbin is introduced into the bowel and a few preliminary sutures taken. It is then filled with fluid and the bowel sutured over it, except where the tube emerges; here the last two or three stitches are left loose. The bobbin is now emptied, removed, and these few sutures fastened.

It was not until after I had devised this lateral anastomosis-bobbin, removable just before the completion of suturing, that I thought of using the same sort of bobbin for the end-to-end method. I finally had bobbin No. 4 made, which comes in the same sizes and styles as Nos. 1 and 2, except that the filling tube enters the constricted part of the bobbin and it is removed before complete union of the edges of bowel has been effected.

This communication is but a preliminary one. Careful experimentation must yet develop which is the better style of bobbin, the one removable from small extra incision or not.

While experimenting with these bobbins I improvised a suture which I believe is new, especially in intestinal surgery. It is a continuous double-knot suture. With it we can use the Lembert stitch or not as we elect. The Lembert stitch gives more perfect and broader apposition of serous surface, but I believe at the expense of the caliber of the bowel from subsequent constriction. In my experiments so far on the living animal I have used this continuous suture in the following manner: needle, threaded with long fine silk, is entered at right angles to the long axis of the bowel, about one-eighth of an inch from its cut edge, passes through the serous, muscular and cellular coats, emerging from the bowel-wall just above the mucosa; it then crosses to the opposite section of the bowel, enters below the mucosa, passes through the cellular, muscular, and serous coats, emerging as near the end as it entered on the other side. This first stitch is tied with

The

a surgeon's knot and the free end of silk cut short. The needle, threaded with the long end, passes through the ends of the bowel about one-twelfth of an inch from the first stitch and in the same manner. The needle is brought across to the opposite side, a double knot taken in the silk just where it had entered for the second stitch, the silk tightened by pulling in the direction of the first stitch, and the knot then set by pulling in the direction of the next stitch. This continues until the circumference of the bowel is united. When the suturing is complete the knots are all on one side, and the stitches placed at right angles to a perfect cross section of the bowel.

When we remove the bobbin before complete suture, the last few stitches will not be placed as true as the others perhaps, and this is an argument against this variety of bobbin, in endto-end anastomosis. In the method of suturing just described there is less apposition of the serous layers than when the Lembert stitch is used, but there is obtained, what is not claimed for any other method of intestinal suture, almost juxtaposition of the edges of the various coats. The cellular coats meet exactly, the muscular hardly less so, and the serous slightly. It is the simplest thing to take an extra running stitch to obtain more serous apposition.

I am at present conducting a series of experiments on animals, the results of which will be given in a later communication. cation. Those already performed seem to indicate that, with these bobbins and a suture as rapid of application as that described, and as efficient, intestinal approximation will be robbed of many of its difficulties.

The abdominal retractor consists of a piece of wire shaped like a horse-shoe, and provided with retracting blades which project into the abdomen and are prevented from slipping by means of small tips. I have used it in a few abdominal operations, including hysterectomy, appendicitis and cholecystenterostomy.

I also wish to exhibit small self-retaining tenacula with points like the bullet-forceps. They are used for holding the bowel in apposition over the bobbin in place of the preliminary stilette, by assisting in saving time.