Chapter M

Take six drachms of this preparation and add carbolic acid 40 minims.

If it be desirable to remove a thickened fold or bunch-like appearance of the mucous membrane, inject the same as you would piles, using the hemorrhoidal compound. It will slough off neatly and heal readily. It is peculiar of the injection of internal piles or of the same strength of medicine into or beneath the mucous membrane, that it tightens and takes up a slack of the membrane permanently, without apparent lessening of the calibre of the gut. It is also peculiar of the treatment and cure of internal hemorrhoids by injection, that no cicatrix, cicatricial tissue or contraction results, unless the operation has been extensive, involving both sides, and an active inflammation has been excited by extraneous causes.

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.

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.

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.

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.

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.

“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.

“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.)

PRURITIS ANI.

Excluding all discoverable local causes whereby the presence of this obstinate affection may be explained, such as piles, ulcer, fistula, oxyuris vermicularis, eczema marginatum, etc., and take the disease unalloyed, or as it may exist in a state pure and simple, and assure a patient thus afflicted that he can be quickly and permanently cured, would not only be presuming too much, but would be stepping beyond the legitimate bounds of all past recorded experiences.

To furnish something of an idea to those who are not already familiar with this seemingly trivial yet rebellious complaint, I here quote the language of Dr. Hoyt, who uses words somewhat extravagantly in the beginning but palliates his feelings down later on with _lotio niger_.

“With what anguish its unhappy victims battle through innumerable sleepless nights fighting this demon of so-called local epilepsy, with its long array of itching, burning, exuding, corroding, exhausting, and blaspheming characteristics, as though they had been brewed by the chemistry of hell. The whole organization becomes a chaotic discord, the disposition is cruelly warped, the countenance shows a sad picture of living woe, the carriage is nearly lost to all laws of equilibrium, and the complete being merges into a throbbing phantom of despair, trembling upon the very threshold of idolized suicide.

“Of course I speak of the most aggravated cases, instances that seldom occur within the experiences of general practitioners. Wherefore then these phenomena? What is the mighty influence that yields so much distress, as all these objective symptoms are but an appearance outflowered by some subtle and specific force. The meager literature upon this subject hobbles upon the crutches of hypothetical inferences, telling you _perhaps_ it is capillary congestion or chronic proctitis, or neurotic hyperæsthesia or eczema, or malaria, suggesting a panoramic array of remedial agencies all unsatisfactory, thereby confessing to a sad condition of helpless empiricism.

“My comprehension of this subject compels me to endorse the parasitic theory, though it may excite your disapproval, and perhaps your ridicule, yet it can be easily verified by directing your management towards the destruction of the parasite, when all symptoms will disappear. Mercury is quoted as nearly a specific for the annihilation of these marauders, and the very best method of administration is by using Lotio Niger.

“Thrice daily the patient should relax, the respiration of the cutaneous surface by the free application of hot water, just as hot as it can be comfortably endured. Then immediately afterwards _while the skin is made absorbent_ by the action of the liquid heat, it should be saturated with this medicine in the most thorough manner. Within three days time the itching will be reduced fifty per cent., but the complete result is attained only after a continued use of from four to eight weeks.

“In many cases there will remain points or patches where the agent does not seem to act, and to these I usually apply the regular unguentum hydrargyri. Avoid all soaps and ointments except as above stated, thereby preventing the obstruction to absorption of the remedy as it has to enter the pores of the skin in order to act upon these energetic enemies that hold their victims under such a terrible bondage.”

It is characteristic of pruritis for the paroxysms of itching to come on mostly after the patient gets warm in bed, at which time the annoyance may be further increased by a moisture or exudation about the anus.

In longstanding cases the skin becomes thickened, horny in texture, and loses its pigment and elasticity. Sometimes portions of the radiating folds will become so hypertrophied and elongated, from the effects of gouging and scratching, that they look like and are sometimes called external piles, which in reality are nothing of the sort, but properly speaking would come within the range and meaning of non-syphilitic condylomata.

I have successfully removed these formations by the same process adopted for the cure of piles. They go through similar changes after injection and open up a cavity surrounded by a ragged, thick, calloused skin, which, after first being cocainized, can be trimmed off with a pair of scissors. If there are several large tabs I do not operate on all at one sitting.

In the treatment of pruritis ani, a thorough search for a local cause and its removal will find a lasting reward in the results obtained.

Of the obscure local causes, perhaps animal and vegetable parasites are the most difficult to find. The injection of a decoction of quassia bark or lime water and carbolic acid, will be efficacious in dislodging the oxyuris vermicularis, which may or may not be seen, like small pieces of white thread lodged between the anal folds.

For the vegetable parasites, tricophyton, etc., (microscopical) sulphurous acid ranging from 50 per cent. up is an old tried remedy. Immoderate eating, drinking coffee, and smoking excites the itching with some. Whenever it be decided that no local or constitutional disease can be found as an assignable cause, and that it is purely neurotic in character, we commence to grope in the darkness for remedies. What relieves one will not another; and what relieves for a time will lose its effects altogether.

Hot water compresses, a little short of scalding, are good for relief and a good intercurrent remedy. Among the remedies highly recommended are linseed oil, thuja occidentalis, carbolic acid, _citrine ointment_, oil of cade, oxide of zinc, compound tincture of green soap, black wash, and _galvanism_. The anode is placed over the perineum and base of scrotum and the cathode against the anus or within the grasp of the sphincters. Claimed to be a specific. Nerve stretching by divulsion of sphincter muscles is also recommended.

Formulæ:

℞ Ung. Citrini ʒ ii
Balsam. Peru ʒ iss
Acid. Carbol. gr. xx
Sulphuris ʒ iii
Cerat. Simp. vel Lanolini ℥ i

M.

℞ Hyd. Chlor. Mit. ℈ iv
Adipis ℥ i

M. Said to be specific for pruritis ani or vulvæ.

℞ Hyd. Chlor. Mit. ʒ i
Balsam. Peru ʒ iss
Acid. Carbol. gr. xx
Lanolini ℥ i

M. et sig. Apply after hot sponging.

℞ Ol. Cadini ʒ i
Acid. Salicyl. gr. xv
Ung. Zinci Oxidi q. s. ft. ℥ i