Part 9

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

℞ Hyd. Chlor. Mit. ℈ iv Adipis ℥ i

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