Healthy Triplets. EDITOR MEDICAL WORLD:-In reporting this case I am aware of the fact that triple births are rather common, being 1 to 6,500 in multiparous women between 30 and 40 years of age. But for triplets to live and thrive as here shown is an unusual occurrence. On May 5, 1914, I was called to see Mrs. Joseph Powell at 7 o'clock a. m., and at 8 o'clock a. m. I delivered her of a girl baby, buttocks presenting: weight 8 pounds. then thought I had a case of twins, and so informed my patient. At 9 o'clock a. m. I delivered her of another girl; presentation: weight 71⁄2 pounds.

I

normal I then I then

1334 pounds; Sarah, 14 pounds; Joseph, 15 pounds. The boy, who was born last, showed signs of low vitality. I thought he would live only a short while; but thisproved to be from mechanical causes only, and he soon came around all right. The triplets are not the care that one would. suppose, but, to the contrary, they have not been sick a single day, and are the source of unalloyed pleasure to the devoted! mother who bore them, the pride of the fond father who endowed them, and the magnet that draws into the home many strange as well as familiar faces anxious to look upon the unusual sight as they occupy

made up my mind that we had something else to contend with; I did not know what, but in a short while, on examination, I discovered an amniotic sac; then at 11 o'clock a. m. I delivered her of a boy, feet presentation: weight 7 pounds. They were three chorions, three amnions, and one placenta.

Mrs. Powell is a blond, tall, weight 160 pounds, 40 years of age. Up to this confinement she had given birth to three children all living, of the following ages: Two boys, 14 and 11; one girl, 5 years. The triplets nurse the mother in addition to being fed on other food. They are 51⁄2 months old, and weigh respectivly: Evelyn,

their little bed side by side very much the same as in the picture.

Lenoir, N. C. C. L. WILSON, M.D.

Mammary Extract in Uterin Hemorrhage.

EDITOR MEDICAL WORLD:-In your November issue, pages 454 and 455, appear two letters, side by side, the one asking for suggestions regarding the medical treatment of uterin fibroids and the other detailing a case of severe menorrhagia which did not seem to respond to medical treatment, and on examination did not evidence any indication for surgical interference, for which help is also requested.

Interaction of Internal Secretions. The editorial suggestions were interesting and profitable, but it occurs to me that some additional suggestions might also be useful. With our increasing knowledge of the intimate relationship of certain of the organs of the body by means of the chemical messengers, called by Starling hormones, we now know that the mammæ and ovaries are intimately related to one another. There is plenty of evidence to warrant the statement that the mammary glands are not merely excretory organs, or milk producers, but that they produce an internal secretion that controls certain other of the internal secretory organs and are in turn controlled by them. It is well known by the majority of medical practicians that certain substances-probably hormonesfrom the pituitary, ovaries and thyroid exert a markt influence on the activities of the breast. I cannot forget one of the meetings of the Seventeenth International Congress of Medicin last year when Sir Edward Schäfer, the physiologist, demonstrated before the Section on Physiology the influence of pituitary extract on the lactating mammary glands of the cat. In spite of the fact that the spectators were

the élite of the world's research men in physiology, including professors of the highest eminence from practically every corner of the earth, there was a schoolboy murmur of enthusiasm and surprise when almost immediately following an intravenous injection of the pituitary principle the milk in the glands squirted out even beyond the dish set to catch it. Even these scholarly men had to admit it was wonderful. This is, however, a little beside the point.

Mammary Glands and Ovaries.

In addition to being controlled by other organs thru hormone influences, the mammary gland, by its internal secretion, exercises a considerable degree of control over the reproductiv organs and particularly the ovary. As a matter of fact, it seems to have been proved that the luteal internal secretion-corpus luteum" is now considered the essential internal secretory part of the ovaries-and the mammary internal secretion balance one another they are virtually antagonists, just like the pancreas and the adrenals, or the thymus and the gonads. This antagonism has been put to extremely good use in therapeutics by the inauguration in Russia of what has been

called mammary opotherapy. This consists in the administration of suitably prepared extract of the parenchyma of glands secured from certain animals, especially goats, ewes and the cow. The extract of the parenchyma contains a principle which tends to neutralize the excess of luteal principle and hence is given in conditions where there is excessiv activity of the ovaries or hyper-ovarism. Now this very condition may be a cause of menorrhagia, and, watching very carefully to ascertain that an organic condition such as a portion of retained placenta, a foreign body, or cancer is not the cause, mammary extract may be used to control the bleeding with remarkable results. It is obvious that, just as your correspondent, Dr. Schultz, suggests, surgical conditions must be ruled out, and, this being done, especially if there are other evidences of unusual ovarian activity, mammary medication may be instituted with considerable possibility of notable improvement.

Physiologic Action of Mammary Extract.

of this remedy is very different from that of ergot. It does not contract the uterin muscles, but neutralizes or counteracts the hormone stimuli which may be the cause of part or all of the excessiv bleeding, constituting a physiologic or chemical antagonist: To be of practical value in matters of this nature the information should be amplified by clinical excerpts, and I can do no more book as being worthy of consideration in than quote a few paragraphs from my

It should be remembered that the action

this connection.

In

According to Battuaud, in menorrhagia of young girls this form of medication has proved very valuable, just as it has in the metrorrhagia of the climacteric. Ovarian congestion, due to salpingooöphoritis and other causes, is reduced, altho, of course, the influence is purely decongestiv, and not directly antagonistic to the infectiv process. hemorrhage due to uterin sclerosis and fibroids, as well as in those indefinit uterin oozings of the menopause which are not associated with malignant growths this method offers a valuable and physiologic means of control. Battuaud has found it useless in the hemorrhage resulting from retention of placental fragments and from mucous or fibrous polypi. A number of writers have called attention to the possibility of diminishing an excessiv menstrual flow and curtailing its undue length by the use of mammary extract. It is also useful in lengthening the abnormally short interval between the catamenia, bringing back the normal rhythm of menstruation as to frequency, amount and duration. Luncz especially credits this method of treatment with remarkable efficacy, and emphasizes its absolute harmlessness.

"Practical Hormone Therapy." reviewed in the August, 1914, issue of THE WORLD.

A study of other references to the subject cannot but impress one with the antihemorrhagic sedativ effects of mammary opotherapy in cases of functional overaction of the pelvic organs; but it should be emphasized that preparations of this character are not styptics, as a study of their physiologic action will quickly show.

Bell reports good results from the use of mammary substance in the treatment of uterin fibroids, and mentions a number of cases in which the tumor disappeared or was decidedly diminisht in size. He showed that irregular hemorrhage, as well as the pain, was much diminisht, and in some cases disappeared altogether. Shober reports similar results, and recommends mammary extract in fibroids, menorrhagia, and metrorrhagia, and states that the addition of a small amount of thyroid extract to the dose of mammary extract assures even better results. Feodoroff also found that uterin myomata associated with metritis were favorably influenced by this form of treatment, and that the usual hemorrhages were considerably reduced. He also noticed that associated mastodynia was relieved.

These experiences were confirmed by Pryor and Krause. More recently Feodoroff has publisht another statistical report of the results secured from the use of mammary extract in the treatment of uterin fibromyomata. He noted a reduction in the size of the tumor in 53% of all cases treated in this manner. Hemorrhage and profuse menses were absolutely controlled in 83%. The pain usually noted in the development of the tumor was abolisht in 40%, and in only 14% was there total failure. This author noticed that there seemed to be a secondary influence upon the intestinal function as the bowels were frequently regulated, and there seemed to be a special advantage where meteorism was present.

Mekerttschiantz records fifty personally-treated cases, and is most enthusiastic in his praise of this method, which he considers "the touchstone for all cases of uterin fibroids" before deciding upon operativ measures. He also supplies the same treatment in all forms of uterin congestion.

The above experiences may not be duplicated in their entirety, but my personal observation convinces me that this is an effectiv method of treatment and that it

deserves, like every other phase of practical organotherapy, to be raised from the obscurity in which it is at present involved. HENRY R. HARROWER, M.D.

880 W. 180th St., New York City.

Treatment of Boils. Carbuncles and Abscesses. EDITOR MEDICAL WORLD:-The treatment of boils, carbuncles and abscesses in general goes a long way to make up the every-day business of the general practician. The more dexterous he is and less pain he gives his patient, the more it adds to his reputation. We commonly speak of a boil or abscess as being ripe when the accepted treatment is a free incision. Fluctuation is usually the indication for an incision. In some locations fluctuation is difficult, if not impossible to detect; for example, in the

hand and feet underneath the tense fascia, especially in the fingers in what is commonly known as felon. Here one must be guided by judgment of the symptoms. The application of hot, moist poultices (the best being a towel wrung out of hot water) will hasten the formation and bring to the surface A timely incision will relieve much suffering and facilitate the cure by preventing burrowing of the pus.

pus.

The incision should be made by a sharp scalpel plunged in with a sudden thrust, and not with a sawing motion, after the surface has been made numb or deadened with ethyl chlorid, which I regard as the best local anodyne for this kind of work.

The first impulse the physician has after seeing the pus flow is to squeeze or press the walls of the abscess together in order to empty the contents. This I regard as an error, for various reasons; first, the exciting of unnecessary pain, which in a sensitiv and hyperesthetic patient is of utmost importance. Second, nature, in her effort to wall off the pus from the surrounding structures, sets up a fortification of new granulations, and if pressure is brought to bear upon the surface these will be broken down and open up new avenues of infection; thereby frustrating the very object

we

are trying to overcome. There is sufficient resiliency in the tissues themselves, and this combines with the new growth of granulations in the walls of the sack to expel the pus. This cannot be improved upon by artificial methods. may occasionally facilitate the healing of slow or chronic abscess by gentle manipulation of the deeper structures.

One

Before leaving this subject I want to call the attention of the reader to the springing up of too profuse granulations, which are apt to occur where considerable sluffing of the skin has resulted. Here nothing gives such satisfactory results as clipping off the granulations with the scissors and then applying the caustic stick, which is practically a painless procedure.

Once more permit me to enjoin upon the reader to avoid probing newly incised abscesses, as I have several times in the

past done. The application of hot, moist bichlorid dressings are beneficial in the post-operativ treatment of abscesses.

DR. M. J. BUCK.

401 Diamond Bank Bldg., Pittsburgh, Pa.

DEAR DR. TAYLOR:-I have read several journals, but THE WORLD is the best of all. Inclosed find check for renewal. "The Business Talk to Doctors" or "The Monthy Talk" is worth the price to me if it had nothing else. W. L. SIMS. Whitmire, S. C.

Some Diseases of the Rectum and Their Treatment.

Reflex Effects and Neurasthenia. EDITOR MEDICAL WORLD:-The evil effect rectal diseases have on the general health are very much greater than the public, as well as many medical men, realize. There is an intimate relation between the nerves of the rectum and the spinal cord, from which the rectum receives its supply direct, and any irritation in this organ will act as a little fuse, constantly irritating and affecting the entire nervous system; therefore, the sufferer goes on studying self-control, fighting hard to subdue the nervous symptoms which light up from time to time in spite of all he can possibly do, and not realizing that the little fuse lighted up at the distal end of the nerves is liable to an explosion at any time, thus wrecking seriously the nervous system, which succumbs to that dreaded state of nervous prostration. A few symptoms leading up to this condition are melancholia, irritability, unusual worry, anticipation of some unusual unpleasantness, and permitting the ordinary things of life to worry him unreasonably, which he would not do if he were in his normal condition.

Then, again, the constant irritation of the rectum from the different diseases affect that organ so frequently, causing an unnatural contraction, because the muscles are, like those of the eye, involuntary, and any irritation of them causes them to contract without the will of the patient, the same as we close the eye when we have an irritant in it. This contraction leads up to the most frequent cause of constipation, which in turn disturbs the stomach, kidneys and liver, and, in fact, every organ in the body, because the great sewer of the system is clogged and the accumulation of fecal matter is being absorbed and taken into the general system, thus disarranging the entire body.

Fissure of Anus.

Occasionally we are called upon to treat a patient whose bowels have not moved for several days, the condition being caused by an irritable fissure, which, in turn, produced the contraction. I had one case of this kind, in which I had to give a general anesthetic and break up the fecal mass with a curet before it could be removed. This patient had not had a bowel passage for over two weeks, all caused by an irritable

*Read Before the Northeastern District Medical Society of Kansas, October 27, 1914.

fissure, which in turn produced a contraction, and it took about thirty minutes to remove the accumulation of fecal material with the patient under a general While this is a very excepanesthetic. tional case, it demonstrates the possibilities of such conditions. I do not claim that all cases of constipation are caused by this trouble, but I know of several cases of constipation of several years' standing which have been cured by curing the fissures.

No one can appreciate unless he has experienced it, the great bodily change that takes place in one's feelings, or the refresht, soothed state on the entire system resulting from the relief of this distress in the rectum.

Frequently such sufferers say they are unfit to transact business successfully and that they are cross and irritable; and such people are often censured when they should not be because they cannot entirely overcome the irritating results of the diseased parts. I know one man, a butcher, who had to quit business owing to the fact that he had lost his customers because he would be so cranky they just quit him to trade with another who was more congenial when they went to purchase meats. He told me that it made him mad to have a customer ask for a drink of water.

Effects of Constipation.

Frequently we find evil effects on the digestiv system as a result of the irritation. of the nervous system by the constipation and the general sluggish condition of the bowels; for when the bowels are clogged and only partially evacuated each day, it is only natural that the stomach should be affected, resulting in the loss of appetite, dull headache, sluggish circulation of the blood and a stupid, worn-out, emaciated condition which is frequently the state of health we find such patients in when presenting themselves for treatment. Then again we frequently have patients who are suffering with what we call reflex pains; that is, pain produced in one part of the body caused by irritation in another. For instance, irritation in the rectum will produce pain in the top of the head, across the shoulders, the back, hips and down the legs sometimes.

Itching Piles.

Our experience with treating rectal diseases is that 50% of the persons afflicted with rectal disease do not understand the

nature of the disease. They think that everything that gets wrong with the rectum is caused by piles. Piles form on the hemorrhoidal veins, while some of the other diseases have nothing to do with the veins or arteries. For instance, what the laity call itching piles are caused by a condition outside of the rectum and many think they are one and the same thing.

Internal and External Piles.

There are the arterial, venous and capillary hemorrhoids. The first are bright red in appearance and the venous are blue or purple and the capillary are dark. The arterial and capillary varieties have a tendency to bleed. The internal hemorrhoids have the power to increase in size, which they almost always do while being handled, making the operation more easy. The action is similar to that of the erectil tissue of the penis and clitoris. The internal hemorrhoids are attacht inside the sphincter ani and the external are outside this muscle. About all that is necessary to know is whether they are large or small and whether they are external or internal.

Treatment of Piles.

The surgical treatment of piles consist of removing the tumors. The manner in which that is done depends on the nature of the tumor and the opinion of the surgeon, whether they are cut away, cauterized away, strangulated with a snare, ligated. and allowed to sluff off or dissected out or a combination of some of these. It depends on the way the surgeon sees fit to operate at the time.

This intense itching around the rectum is best treated by dividing the nerve fibers near the surface. I am a firm believer in the radical cure of piles. I mean, to remove them. The manner in which this is done depends on circumstances, but there are other ways and some prefer them. But the physician can secure larger fees if he has an anesthetic given and one or two extra physicians and a trained nurse or two around when the work is done. It looks more like something is being done; while if he uses a little local anesthetic, very quietly injects something into the hemorrhoids and tells his patient to return in the morning to be drest it doesn't seem like anything has been done. But let me remind you that before the next morning arrives he will change his opinion about what has been done.

The drugs that have been used for the treatment of hemorrhoids are many, but the specialist, the quack, the general physician and all who are skilful in the treatment of these conditions have thrown all aside for one; that one is carbolic acid, alone or in combination with something else, and the stronger the solution is in acid content the better. Never use it weaker than 40%. The common formula and the best is R Acidi carbolici

Ol. olivæ.....

:

.....equal parts

Sig. Inject enuf to cause the tumor to turn white; wipe the tumor with pure alcohol. Apply a soothing ointment, and the job is done.

It is sometimes a good thing to use a snare to choke the blood in the tumor while

injecting it, but not always necessary. One or two only should be injected at one treatment. This form of treatment applies to internal piles. The external variety should be cut off and treated the same as any other wound.

Here is a favorite method and successful one; after surrounding the pile with the snare inject the solution; this will produce the anesthesia needed. Then make the circular cut of skin and mucous membrane and ligate the pile; then the tumor is snipt off and the stump treated same as any other wound.

I wish to here remark that with the ordinary injection plan the treatment sometimes has to be repeated as many as three times.

Rectal Fistula.

There

Rectal fistula is not uncommon. are the complete variety which has two openings and the incomplete variety with only one opening; also the external and internal varieties. The treatment of these conditions consists of destroying the scar tissue surrounding the canal (or the pipe) and healing it by granulation. The destruction of this can be done by the use of the knife or by the injection of the carbolic acid solution, or iodin or others. It is well after the injection of the fistula to leave a little gauze in the opening to answer as a wick for drainage. Every canal must be treated alone or the work will not be a success, and I will here state that I have seen one case with one external opening and five internal openings. All must be attended to or the operation will be a failure. This injection of a fistula must be repeated every third day till cured. The following is Brinkerhoff's injection fluid: