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. [Illustration: 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. [Illustration: FIG. 28.—Long blunt hook.]