had occasional bleeding and also protruding masses at the anus for the past 30 years. His immediate complaint was severe pain at the anus, and protrusion of tissue during stool. Although he had a frequent desire to defecate he could pass nothing but mucus. The attendant straining was accompanied with cramp-like pains in the lower abdomen. After each attempt to defecate he had to anoint the anus with vaseline, and through the aid of this was sometimes successful in returning the protruding mass with his fingers. Examination revealed external and internal hemorrhoids, and a congestive coloproctitis with slight ulceration. A solution of %% cocaine was injected into the protruding mucous membrane, until blanching of the tissues, and the tumor turned a glistening white. This indicated that we had produced local anesthesia. The tumor was then grasped with a clamp, and severed at the muco-cutaneous junction, dissected up as high as possible; a ligature was placed around the mass after tying off as much as possible of the redundant tissue. was cut off, enough of the stump being left to prevent the ligature from slipping. He had no pain during the operation, only slight after-pain following the operation, and since then has had only one movement a day. Evidently this tumor acted as a foreign body, and brought on a reflex desire on the part of the rectum to expel this mass, thus causing a relative frequency of stool. It CASE IV. H. T. A. Male. Real estate broker, age 42. Has complained of "piles" Has complained of "piles" for the past twelve years, with occasional bleeding, is constipated, and has resorted to the use of suppositories and salves for temporary relief. Ten months ago, he noticed after a hard evacuation, a burning pain at the anus, and also a drop or two of blood on the toilet paper; and since then he has had severe pain after every stool lasting for four or five hours. The pain is so severe that he actually is afraid to go to stool for fear of the pain he anticipates. On examination, a protrusion was found at the posterior anal margin, commonly known as the "sentinel piie," and on separating its folds, a well marked fissure was discovered within the grasp of the sphincter muscle, much inflamed and exceedingly sensitive. A solution of B. eucaine %% was injected with the Saphir syringe, about 1⁄2 inch posterior to the anal margin, into the tissues for a distance of about 1 to 12 inches in depth. Then the sphincter muscle was cut through the fissure, perpendicularly to the transverse fibres of the sphincter muscle, relieving the spasm of the sphincter muscle at once. The skin-tags forming the "sentinel pile" were then clipped off, a strip of moist gauze was inserted into the wound for drainage, and a dry dressing and "T" binder were applied. The patient went home, went to business the following day, and called for daily treatment at my office. This man was a horseback riding enthusiast, and his participation in the pleasures of his favorite sport was not interrupted by the operation. CASE V. J. B. Male. Broker, age 30. For the past five years he had noted a prominence between the end of the spine. and the anal margin, which grew larger and larger until it is now the size of a walnut. Six weeks ago, he noticed pain and swelling. On application of hot poultices, an abscess formed and burst, and has been discharging ever since. Examination disclosed a mass about the size of a walnut which was filled with the caseous matter of a broken-down cyst, and a fistulous tract with its internal opening between the external and internal sphincter muscles. With %% eucaine hydrochloride solution, the tissues at the base of the dermoid cyst were injected, then along the fistulous tract, and deep down into the sphincter muscle until we got infiltration anesthesia. The dermoid cyst was then shelled out, the fistulous tract was opened up and curetted, the external sphincter muscle cut, a gauze drain inserted to the bottom of the wound, and finally a dry dressing and a "T" binder applied. The patient left the office, felt no pain and attended to his business the next day. CASE VI. Mrs. D. G. Housewife, age 37. Complained of rectal trouble, protruding piles and bleeding for the past six years. One week ago, she noticed protrusions at the anus accompanied with bleeding after stool, the pain lasting for about one hour after stool. Patient was constipated, her condition necessitating the , 1913 , Vol. VIII, regular use of cathartics. These protrusions came out regardless of any relationship to her bowel movements. Examination revealed two large interna! hemorrhoids. With the Saphir syringe for local anesthesia, some sterile water was injected until the tissues became blanched and anemic, and the mucous membrane had turned a glistening white, showing that a sufficient amount of pressure had been put upon the nerve endings to produce local anesthesia (the same amount of pressure usually necessary to force the blood from the capillaries is enough to produce local anesthesia). The tumor was grasped with a clamp, pulled down, nicked at the mucocutaneous junction and dissected up from the muco-cutaneous junction, ligated as high up as possible and cut off leaving enough of the tissue to give the ligature a chance to hold. The patient had pain only while the water was injected (distention pain) but no pain during or after operation. CASE VII. Mrs. P. L. Housewife, age 50. Has had hemorrhoids for the past nine years. Two months ago, she noticed protrusions at the rectum during stool; continuous pain after stool; stool followed by bleeding; was constipated to an extent necessitating daily use of cathartics. A diagnosis of internal hemorrhoids was made. A few drops of water were injected into the hemorrhoid until it was brought outside of the sphincter muscle, and turned a glistening white, when it was grasped by a clamp and pulled down, cut at the mucocutaneous junction and dissected up as far as I could reach, and the redundant tissue tied off with linen thread. This woman had slight pain during the injection of the water due to distention, but had no pain during or after the operation. She went home immediately after the operation and felt no inconvenience. CASE VIII. B. B. Male. Trunk maker, age 29. Has suffered from hemorrhoids and constipation for the past two years. Five weeks ago after straining at stool he noticed a protrusion accompanied with pain on sitting and walking. He could not sit at all for two days. Has no bleeding, but could not replace this protrusion. On examination I found a bluish lump, size of a small nut, diagnosed it as a thrombotic hemorrhoid injected a few drops of water, incised the tumor with a curved bistoury, turned the clot out, and after curetting the base and walls, put a small drain of plain moist gauze to prevent the cavity from refilling as well as to maintain proper drainage. The patient had no pain other than the distention pain during the injection of water, and after the operation went about his business. CASE IX. S. M. Male. Public accountant, age 24. Had had no rectal trouble until the day he was brought to me. While walking rapidly along the street, on his way to catch a train, he complained of a sudden pain as if he were shot, his knees bent under him, and he could not walk any further. He fell to the ground and felt, as he explained it, "a sudden attack of piles." He was brought into my office, when on examination, a large hard, bluish looking tumor was discovered at the anal margin. A diagnosis of thrombotic hemorrhoid was made. After injecting a few drops of water with the Saphir syringe, until the tissues had become blanched, the tumor was transfixed with a curved bistoury, and the blood clot turned out, with almost no pain. The edges of the incised wound were clipped and a narrow strip of plain moist gauze was passed to the bottom of the wound to insure proper drainage and to prevent another clot from forming. He was immediately relieved, was able to sit and to walk comfortably. In a short time he left the office, and has been attending to his duties ever since. CASE X. N. S. Male. Actor, age 33. Has complained of "piles," for the past eight years. His last attack began six months ago with obstipation lasting for twelve days followed by a hemorrhage per mouth. He complains of constipation which necessitates his taking daily enemas or cathartics, and has also noticed protrusions at the anus and occasional bleeding after defecation. He also complains of pain in the lumbar region during and after defecation. Examination revealed a mass of four protruding internal hemorrhoids, which were ulcerated. When requested to strain, the tumors became congested and commenced to bleed from the ulcerated areas. The man was sent to The People's Hospital, and prepared for operation with the usual antiseptic precautions; a 2% solution of quinine and urea hydrochloride was injected into each tumor until the tissues became blanched indicating that local anesthesia was produced; each tumor was then grasped individually with a clamp, pulled down, severed at the muco-cutaneous junction, dissected up from the submucous tissue, and ligated as high up as possible with linen thread. A dry dressing of sterile gauze and a "T" binder was applied, and the patient put to bed. He did not complain of any pain during or after the operation. The next morning, he was given a cathartic, which was effective; he had a good movement, was then placed on a full diet, and on the third day went home and to business. CASE XI. I. G. Male. Presser, age 37. Complained of a mass protruding at the anus for the past four years. He was quite constipated, has had no bleeding, but had a small tumor the size of a nut externally, which he could not replace. A diagnosis of external hemorrhoid or skin-tag was made, a few drops of quinine and urea hydrochloride solution, 2%, was injected into the skin-tag, when after one or two minutes (it takes that length of time for this local anesthetic to act, and sometimes you must wait 20 minutes for the local anesthetic effect with quinine and urea hydrochloride solution), the skin-tag was removed in an inverted "V" shaped section, the vortex being toward the periphery. Two stitches were placed to pull the edges of the wound together. The wound healed by first intention, the patient suffered no pain. I would recommend the use of quinine and urea hydrochloride solution for skin-work in 4% or 2% solutions in preference to water, or cocaine or eucaine, especially on account of the fact that there is greater amount of sensation in the skin than in the mucous membrane. CASE XII. P. G. R. Male. Printer, age 28. Had had rectal trouble for the past four years, had protrusions during stool, was very constipated, had occasional bleeding with his stool, but no pain. Felt, however, as if his act of defecation was never completed, and that he must always take cathartics to secure a satisfactory movement. Examination revealed strangulated internal hemorrhoids, somewhat ulcerated. This man objected to a general anesthetic. He was sent to The People's Hospital, walked up to the operating room, and was prepared for operation. A solution of quinine and urea hydrochloride % was injected into the hemorrhoids until the tissues became blanched. The hemorrhoids were then grasped with a clamp and pulled down. With a pair of blunt curved scissors the hemorrhoids were nicked at their muco-cutaneous junction and dissected up, so that the ligature after the operation would not lie within the grasp of the sphincter muscle. The hemorrhoids were then ligated as high up as possible with a heavy lien thread, and the hemorrhoids removed but not too close to the stump, so as not to allow the ligature to slip. The patient complained of absolutely no pain, got down from the operating table without assistance, went home and has been feeling comfortable since. In conclusion I would add that of the local anesthetics used: 1. Ethyl chloride spray can be used in thrombotic hemorrhoids when external to the sphincter muscle, in opening abcesses or furuncles on the buttocks or about the anus, but is not practicable in rectal conditions within the rectum or above the anal or sphincteric margin. 2. B. eucaine solution can be used in all rectal conditions, but should be used in %% or 1/10% solutions, and although less toxic than cocaine may produce toxic effects on the patient within five or ten minutes. after the operation. 3. Cocaine solution should never be used in rectal operations in stronger than %% or 1/10% solution, toxic symptoms showing themselves more frequently and sooner when cocaine is used about the rec , 1913 , Vol. VIII, tum, than when used at any other part of the body. 4. Patients operated under local anesthesia of cocaine or B. eucaine have no pain during injection of the solution or during operation, but often do complain of severe excruciating pain, weakness and faintness, attended with a cold sweat within about five or ten minutes after operation. 5. When using cocaine or B. eucaine solution for local anesthesia, it is wiser to insert a rectal suppository of morphine sulphate gr. 4 before the operation, or to give a hypodermic of morphine sulphate gr. 4 immediately after the operation, to control the severe pain which invariably follows the operation. 6. Sterile water solution while producing some distention pain during infiltration gives no pain during or after operation. While it is to be preferred in mucous membrane operations where the pain is almost nil, due to small nerve supply, it is not as feasible in skin work, where sensation is greater due to increased nerve supply. 7. Quinine and urea hydrochloride solution is the anesthetic of choice in rectal operations. A 1% solution should be used in mucous membrane work where sloughing followed by scar-tissue formation is desired, and a 4% or 3% solution should be used in skin work. If used in stronger than 4% or 3% solution in skin work primary union of the tissues will not be obtained. Quinine and urea hydrochloride solution produces anesthesia in from three to twenty minutes, but the anesthetic effect lasts for a period of from three to ten days, a sufficient length of time to allow wounds, resulting from ordinary rectal operations to heal perfectly. 118 First Street. THE ACTION OF THE PERISTALTIC HORMONE AFTER ORAL AD- BY H. J. ACHARD, M. D., Chicago, Ill. Since Zuelzer investigated the function. and action of the peristaltic hormone, a not inconsiderable number of reports on the efficiency of this substance in various conditions of constipation has appeared in German and American literature. Zuelzer has assumed (Die Therapie der Gegenwart, 1911, p. 197) on the ground of his animal experiments that a peristaltic hormone is formed in the gastric mucosa during the process of digestion, and that this is most probably stored up in the spleen. It will be remembered that the term hormone was coined by Starling, and that by it he designated a group of substances which are formed during the normal metabolic process of certain cells of the animal organism. Their significance lies in their dynamic influence upon the living cell, and they are secreted during the performance of the normal body functions, and carried. by the blood stream to certain organs which they stimulate to a specific function. The peristaltic hormone would then give the impetus, as it were, to the peristaltic waves throughout the intestinal tract, by which the contents of the intestines are propelled through the gut. It was found in animal experiment that after intramuscular or intravenous injection of the peristaltic hormone, a peristaltic wave may be observed, which passes from the pylorus down and continues to the rectum. This stimulation persists in animals as long as half an hour. At the suggestion of Zuelzer the peristaltic hormone was prepared from the spleen of sheep by Schering of Berlin, and given the name of hormonal. In clinical experiments it was found that from one-fourth or one-half hour to several hours after the intravenous administration of hormonal the intestines, which were hitherto entirely quiet, commenced to contract, which process resulted in more or less copious defecation. Such an effect was observed in several cases of chronic obstipation, and especially in post-operative paralysis of the intestines in which colonic injections of laxative solutions had been employed without result. It was further noticed that the effect of a single dose of hormonal persisted for weeks and months, suggesting that the preparation exerted a lasting stimulating action upon certain nerve centers by which the process of peristalsis was regulated. While the intravenous and the intramuscular administration of the peristaltic hormone is quite feasible in hospital practice, it is not always possible to persuade private patients to submit to the discomfort and to the pain, the more so as an absolute promise of results can, of course, not be given. There were certain cases of protracted and habitual constipation in which the administration of the remedy remained without results. For this reason, and still more for another reason, it appeared to me desirable to inquire whether the peristaltic hormone would not act just as well or at least satisfactorily if introduced into the stomach. The other point which led me to inquire into this problem was the following reasoning: If the peristaltic hormone is normally secreted in the gastric mucous membrane during the process of gastric digestion and incites the production of the peristaltic wave, an insufficient digestion and an insufficient degree of peristalsis, leading to constipation, may at least in part be assumed to be caused by the deficiency of the peristaltic hormone in the gastric secretions. It appeared to me a priori reasonable that the introduction of a plus of peristaltic hormone would lead to an improved peristalsis, and that the intramuscular or intravenous administration of the remedy which is always disagreeable and, as some of the reports suggest, not entirely without danger, could be avoided. Messrs. Schering and Glatz, of New York, very kindly transmitted to me a supply of hormonal in addition to the amount which I had bought myself for the purpose of determining the possibilities of their preparation by oral administration. The preparation was given to four persons, three of whom were in good, respectively, fair health, except for an obstinate constipation which had existed for years; while one is neurasthenic and has for many years suffered from intestinal insufficiency, malnutrition and other conditions in addition to a practically total atony of the lower bowel. These patients were selected on account of their intelligence because I could be sure that they would cooperate with me after having had the problem explained to them in detail. The neurasthenic patient referred to, who is a man of fifty odd years, and a young man twenty years old, derived no benefit whatever from two doses of hormonal that had been taken after a preliminary cleaning out, and these two need therefore not be considered further in the present report. The third subject of my experiment is a woman forty-four years old, unmarried, |