Treatment of hemorrhoids, and other non-malignant rectal diseases

by W. P. Agnew

RECTAL POCKETS AND PAPILLÆ.

Concerning the frequency of the diseased conditions to which the names rectal pockets and papillæ are applied, and their being such prolific sources of mischief as claimed by those who first caught up the craze and exaggerated the facts, a few brief comments may not be out of place.

That there are such morbid changes, and that they are more or less hurtful through reflex excitability can not be successfully disproved. That their appearance suggests the titles they have received is also undeniable. And the fact of their having been brought to notice in an irregular way, does not militate in the least against the existence of such affections, or the fitness of the terms used to designate them.

If it be true, as stated by enthusiasts on the subject of rectal pockets and papillæ, that they are frequently found in old, deep-seated, chronic diseases, where the presence of rectal trouble is never suspected by any local signs, we have, then, a sufficient reason to account for their having escaped the notice of specialists.

Andrews makes a labored effort, and with apparent success, to show that the so-called “pockets and papillæ” are normal structures. That the pockets are the sacculi Hornei ([Fig. 22]), which are little depressions situated just above and intimately connected with the verge of the anus, caused by the reticulated arrangement of bands of muscular and connective tissue, beneath a delicate mucous membrane and deepened by the corrugating action of the sphincter ani. That the papillæ are little dot-like prominences frequently found between the lower ends of the sacculi Hornei, and when somewhat enlarged resemble in appearance the carunculœ myrtiformes of the vagina. That these little papillæ, with their adjacent “pockets,” constitute the so-called “pockets and papillæ” of the itinerant.

Fig. 22.—S. Sacculi Hornei. P.P. Papillæ, magnified three diameters. (Andrews.)

Fig. 23.—P. Bone fide rectal pocket with adjacent papillæ, not magnified at all.

I have seen just what Dr. Andrews very correctly describes, and will say, after carefully reading his explanation, I am fully convinced that he never saw what is meant by the discoverer of rectal pockets and papillæ. And further beg to say that the doctor must concede that there are others, who are not itinerants, capable of identifying a diseased surface when they see it, and pointing out its place of location.

Fig. 24.—Other varieties of papillæ and a simple form of rectal pocket.

It will be seen by a reference to the appended clipping, that Andrews has been making his microscopical dissections nearly an inch below where true rectal pockets are found. And I can conscientiously attest that true papillæ bear no resemblance, in the least, to his papillæ or carunculœ myrtiformes at the anal verge.

Fig. 25.—Represents [figure 22], showing reticulated arrangement under post mortem relaxation. C.C.C. Columnæ recti. S. Sacculi Hornei. P.P. Papillæ. (Andrews).

Rectal pockets are doubtless a duplicature of the mucous membrane, forming cul-de-sacs with their mouths looking upwards. They are removed through a speculum by raising the outer wall with a blunt hook and excised with a pair of scissors, or slit through their center with a knife, and carbolic acid applied to the remaining flaps.

Fig. 26.—Author’s Knife-hook for slitting down pockets.

Papillæ may be seen in three different forms. One, a white, flat or sessile process, resembling the half of a split pea, but not quite so large. Another, a small, white, rather stiff projection on either side of a large pocket. The other, a slender, perfectly flexible, worm-like vegetation, possessed of a white or transparent top, [Figs. 23 and 24]. They appear to spring out of the mucous membrane similar to a polypus, and can be snipped off at their base with little loss of blood and trifling pain.

“The usual location of pockets and papillæ is at a point about an inch from the anus, at the upper margin of the internal sphincter, where the large distended pouch of the middle portion of the rectum is abruptly puckered down to the narrow limits of its last inch.

“These pockets are curious formations, and have received very little attention from writers upon rectal disease, and they have been almost entirely overlooked by anatomists, as well as pathologists. Whether they belong to the anatomy or not, I am unable to state with any certainty, but I know for certain, however, that they are not always present. I know also that they can almost always be found in cases of old, deep-seated, chronic diseases, and that the removal of these pockets in this class of cases is followed by the most happy results.

“When these pockets are present, they always occasion a spasmodic contraction of the sphincter ani, a condition which is most frequently observed in those cases that are developing some deep seated constitutional disease. Their removal in this class of cases is invariably attended by more or less improvement of the patient’s general condition and circulation.

“In form and character these pockets may be long and narrow channels, and ulcerated at the bottoms; short (cul-de-sacs) or broad mouthed and pointed at the bottom. These pockets create a great amount of irritation to the nervous system. No matter what shape, condition or location they may be in, by reflex irritation they produce a long train of nervous symptoms that cannot be remedied until they (the pockets) are removed.

“Papillæ are conical processes of mucous membrane, of variable size, shape and location. They have no relationship with rectal pockets, for they very frequently exist independently of them.

Fig. 27.—Pratt’s curved scissors.

“I look upon these conditions as being the most mischievous of rectal disorders, because they always occasion a tonic spasm of the internal sphincter, and this alone makes excessive demands upon the powers of the sympathetic nerve. They are common in all forms of chronic disease. I know of no reason why these conditions, which I have described should have been so long overlooked, and their importance have remained unappreciated.

Fig. 28.—Long blunt hook.

“Unless it be that their presence is unattended by local symptoms, and hence they have failed to attract the attention of either patient or the physician. But in view of the fact that they occur in so many chronic conditions, and the additional fact that marked benefit almost invariably follows their removal, I insist upon it that no obstinate case of chronic disease has been properly examined until their presence or absence has been ascertained. The most happy and the most marvelous results that I have ever seen in the practice of medicine and surgery have followed the removal of pockets and papillæ, and in thus bringing them to your notice, I do so in the confident belief that a proper appreciation of their importance on your part will add materially to your resources in battling with disease, and in helping those who apply to you for relief.” (Pratt.)