CHAPTER Xni. (Part 1)

CHAPTER Xni. PRURITUS AN"!. Pruritus generally a Symptom of some other Disease. — Description. — Causes. — Relation of Internal Haemorrhoids, Fistula, Worms, Parasites, and Eczema to Pruritus. — Treatment of Eczema. — Herpes and Erjrthema. — Constitutional Conditions causing Pruritus. — Dependence upon Constipation. — ^Treatment of Constipation. — GreneraJ Treatment of Pruritus. Pruritus ani — itching at the anus — is generally a symptom of some other disease such as haemorrhoids or eczema, but it is often present in a marked degree when no cause for its existence can be discovered. It is an exceedingly painful and annoying affection, and one which will often tax the powers of the surgeon to the utmost for its cure. It is met with in both men and women and seems to be dependent upon no particular general state, being found in rich and poor, the overfed and underfed, the professional man of nervous constitution and the laborer, alike. The disease is marked by an itching at the anus which is more or less constant, but is generally worse after the sufferer has become warm in bed at night. The itching causes an attempt at relief by scratching, and the scratching, though it may be controlled during the day, is generally practised unconsciously during sleep to an extent which causes laceration of the skin. The itching in bad cases, even when constant, is marked by exacerbations and remissions, and may cause an amount of suffering which is simply unbearable. The diseaso is attended by certain changes in the appearance of the parts. The skin becomes thickened and parchment-like or else eczema- tons and moist from exudation. It may be red from the scratching, or there may be quite a characteristic loss of the natural pigment of the anus. In the latter case the skin becomes of a dull- whitish color, and this will oftened be noticed where the disease is of long standing and severe. The exudation may be very marked where the itching is slight, and may be attributed by the patient to trouble within the rectum instead of to its real source. Causes. — The cause of pruritus may sometimes be easily discoverable and in such cases a cure rapidly follows its removal. For example, pruri- tus is often a symptom of internal haemorrhoids and is easily and effect* 270 DISEASES OF THE RECTUM. AND ANUS. ually cured by their removal. Again it is often a symptom or complica- tion of a fistula with a small external opening such as may easily be overlooked in a cursory examination; and is cured by the ordinary opera- tion and the consequent cessation of the discharge upon which it depends. It is often dependent upon the presence of the oxyuris vermicularis in the rectum and in etery case these should be carefully looked for. If they are present they may generally be seen like small pieces of white thread between the radiating folds at the margin of the anus, especially at night when the itching begins. They may generally be eradicated by certain simple measures, the best known of which is an enema of lime- water, or of carbolic acid, 3 i. ; glycerin, | i.; and water, 1 vij., injected after each passage. Turpentine and tincture of iron may be used for the same purpose and are both very effectual; but the parasites are much more easily removed in children than in adults, and I have had one case which was exceedingly intractable, and in which I have never been able to keep tho worms from returning for any great length of time. A single examination should never be considered as proof of the absence of this parasite in an obstinate case of pruritus. Instead of a parasite located within the rectum, pruritus is occasion- ally easily accounted for by the presence of pediculi. In such a case the diagnosis and cure are alike easy. Again the parasite may be vegetable instead of animal, and the itch- ing may be due to the disease known as eczema marginatum. In this case the diagnosis will rest upon the finding of the spores under the micro- scope in the epidermis scraped from the edge of the affected spot and moistened with glycerin. The most effectual remedy for this condition is a wash of equal parts of sulphurous acid and water frequently applied with a soft cloth, and gradually increased in strength, if necessary, up to the pure acid, which latter is, however, generally a painful application. Strong tincture of iodine applied with a brush is also an effectual remedy in eradicating the plant. Pruritus may also be dependent upon other skin diseases, among which chronic eczema is perhaps the mosfc common, and this is to be treated exactly here as elsewhere in the body, first by general measures directed to the constitutional state, and second, by local applications. The conges- tion and the thickening of the skin must first be remedied, and for this purpose very hot water, compound tincture of green soap, and if neeesary a solution of caustic potai^ may be applied! The water, to be of any use, must be as hot as the fingers can bear, and should be applied to the part with a soft cloth and held there till it begins to cool. This may be re- peated half a dozen times, but all rubbing should be carefully avoided both during the application and in drying the parts after it. This is a favorite remedy with most dermatologists; it should be used just before going to bed, and is often in itself suf&cient to insure a good night's sleep. PSUBITUS ANI. 271 If there be thickening of the skin from effusion^ a stronger application than hot water will be necessary; and for this the compound tincture of ^een soap is a good remedy; or the solution of potash (gr. v.- 1 i.) or liquor potasssB may be resorted to with caution. The formula for the compound tincture of green soap is the following: 5 Saponis viridis, Olei cadini, Alcohol d.a I i. M. It is a much stronger preparation than the simple green soap and also a much more disagreeable one, but it is very effectual and should be well rubbed into the part once a day. These remedies should be followed at once by soothing ointments, or lotions. A good ointment is the ordinar oxide of zinc made soft and applied gently, and one which is pretty cer- tain to allay itching is that made of chloroform ( 3 i.- 1 i.)- This soon loses its power by the eyaporation of the chloroform and should on this account be kept in a wide-mouthed glass bottle, tightly corked, and should be frequently renewed. Another favorite application, and one which is yery generally effectual, consists in a lotion of carbolic acid. The formula is: ]$ Acid, carbolic! § ss. Glycerinse I i. Aquae | iij. M. This may be applied at night, and if found to be too strong may be diluted by the patient. In a more dilute form it may also be continued for a considerable time after all symptoms have ceased. For the sake of those who have never encountered an obstinate case of this disease, but who are pretty sure at some time to have both knowl- edge and ingenuity taxed to the utmost, I will give one or two more for- mulas which have been found reliable. The following comes from AUing- ham, and by it alone he has ''seen a bad case cured in forty-eight hours," ]$ Liquoris carbonis detergens (Wright's), Glycerinae a& | i. Pulv. zinci ozidi, Galamin. prep ; aa | ss. Pulv. sulph. precip * 3 ss. Aquao purao ad § vi. M. The part affected is to be thickly painted over with this once or twice a day and allowed to dry. The white precipitate ointment mad9 soft with vaseline or glycerin is also a good application, and the following lotion, also from AUingham, will often work well in allaying irritation: 272 DISEASES OF THE SECTUH AND ANUS. ]^ SodaB biboratis 3 ij. Morph. hydrochlor .♦ : gr. xvi. Acidi hydrocyanic, dil | ss. GlycerinsB | ij. Aquse ad | viij. M. This should be applied to the part four or five times in the twenty- four hours. Dr. Bulkley' has also recommended the following as being useful^ and 1 have often found it so. 9 Ungt. picis 3 iij. " bellad 3 ij. Tr . aconit. rad 3 ss. Zinci oxidi 31- Ungt. aquas ros 3 iij. M. An ointment of chloral and camphor, a drachm of each to the ounce, is also at times effectual in allaying itching. There are two other skin diseases either of which may be the cause of pruritus — herpes and erythema. Herpes at the margin of the anus is the same as when seen on the lips. . In the latter case it heals spontaneously, in the former a dressing may be necessary. This may consist simply of a dry powder such as zinc or bismuth, or of one of the lotions already mentioned. Erythema will be found chiefly in fat people where it is due to contact of the opposing cutaneous surfaces. It also is best treated by the application of dry powders, and by separating the opposed sur- faces by a* layer of dry sheet lint or old muslin. These are the most palpable and perhaps also the most common causes of pruritus, but there are many cases in which the cause is not so easily discoverable, because it is a constitutional and not a local one. Where no local cause can be detected, a careful inquiry must be instituted with regard to the patient's general health and habits. If chronic con- stipation be present, this must first of all be overcome, for this is in itself an efficient cause for the disease. The treatment of chronic constipation is by no means a simple matter. It may be begun with a purgative such as three compound cathartic pills, for the sake of opening the way for future treatment, but here the administration of purgatives should end, for their repeated administration is calculated to do harm rather than good, by substituting an occasional over-action for the daily one which indicates a healthy state of the intestinal tract. The following sugges- tions may be found of use in the treatment of this condition which is one that must be overcome at the commencement of the treatment of any rectal affections with which it may be associated. Constipation may be due to deficient action of either the small or the large intestine, and this deficient action in either case may be the result either of deficient secretion or deficient nerve power. 1 The Med. Record, December 18th, 1880. FBUBITUB ANI. 273 Deficient secretion is very apt to be associated with hepatic disturb- ance, and is marked by dull headache, bad taste in the mouth, viscid secretion from the buccal glands, etc. This is a condition pretty sure to be aggravated by cathartics, for the reason that the temporary increase in secretion which they cause is followed by a corresponding decrease? which serves only to make the patient worse than before. For the purpose of increasing the natural secretion of the small intestine, the fruits contain- ing citric acid, such as oranges; and other fruits, such as figs and apples, when the patient can digest them, all serve a good purpose. Water is also an excellent remedy, and two tumblerf uls of it taken in the mornmg will often be very beneficial. To it may be added a slight saline, which decreases its capability for absorption ( 3 ss.-0.i.), and, therefore, increases the peristalsis; and the addition of a single grain of quinine is said to greatly increase the effect.* This treatment, if patiently "persisted in for a few weeks, will generally be followed by a good result. Deficient innervation will be found in most cases of constipation in old people, people of sedentary habits, and those who have little exercise. It is generally attended by deficient action of the skin and a sallow com- plexion. In such cases water will be found only to weaken the digestive power, unless it can be combined with a different mode of life and abundance of out-door exercise. Cold bathing, however, cold against the spine and abdomen, plenty of exercise in the open air, and nux vom- ica will generally be found to give relief. In constipation dependent upon the large intestine, the trouble will generally be found to be due to deficient innervation rather than to any lack in the secretion. It is best treated by keeping the rectum empty, by nux vomica, or belladonna in doses sufficient to cause dryness of the throat, and by electricity. The latter should be in the form of the Pa- radic current, one pole being placed over the spine and the other passed up and down along the track of the colon. Infantile constipation may be due, as pointed out by Jacobi, to the disproportionate length of the sigmoid fiexure. In children it is not un- usual to find two, or even three, flexures in the lower part of the colon, in which the faeces may remain until they become hard and friable, and when such an anatomical formation is associated with a deficiency of the intestinal secretion, a very obstinate constipation, and even impaction, may result. In such a case oat-meal is to be given in preference to tapi- oca, rice, or barley, and with it an abundance of water. Purgatives should never be administered except in extreme cases, enemata being pre- ferable.' Faecal accumulation is not very uncommon in young children. In chronic constipation, the patient should first of all be instructed to have a regular time for the daily evacuation, and the best time for this purpose is immediately after breakfast. The time being fixed, the patient 1 Thompson, New York Med. Record, May 5th, 1877. « N. Y. Med. Record, Sept. 25th, 1880. 18 274 DISEASES OF THE RECTUM AND ANUS. is to go to the closet whether the desire for a passage be present or not, and pass a certain time upon the commode. I generally recommend the time immediately after the morning meal for this purpose, because the breakfast itself often acts a stimulant to this function, especially in those in the Rabit of taking a morning cup of coflfee. If the patient be a man in the habit of smoking, the first few whiflfs of smoke often act in the same way; and there are many men to whom the morning cigar or cigar- ette is an essential to the daily evacuation. In such a case it must be a very decided opponent of the weed who would object to its continuance in moderation. If the plain cold water taken in the morning has no effect, the minr eral waters may be tried in its place with great advantage; and the patient may select the one most agreeable to the taste and which most effectually accomplishes the desired end. The morning meal may consist of what- ever the patient most desires, but a dish of oat-meal or coarse cracked wheat and milk should always be an essential part of it. A laxative bread may be made of eqaal parts of coarse Scotch oat- meal, whole wheaten flour, and coarse ordinary flour, with yeast or baking power. This may be eaten once or twice daily.' I have almost always found that where perfect regularity in the daily life with regard to eating and exercise can be established, the function of defecation will also be performed regularly, provided the diet be plain and rather coarse in quality. To have a copious, well-formed evacuation it is necessary flrst of all that the diet should be composed of substances which leave a considerable quantity of waste, and chief among these are the coarser grains and the vegetables. In women a certain regulated amount of daily out-door exercise should be insisted upon, in spite of all excuses and professions of disability. If necessary, this may be small at first, and gradually increased; and in a woman who has lost the habit, and, perhaps, almost the power of walking, considerable tact and firm- ness on the part of the physician may be required to carry out this part of the treatment, but it will be found to be care well spent. In addition to these dietetic and hygienic rules, certain medication may and often will be found necessary. This should be of the mildest possible kind which will accomplish the object. A pill which I have found to act very effectually and pleasantly under these circumstances is made after the following formula : 5 Pulv. aloes soc gr. iss. Ext. nucis vom gr. ss. Ext. belladonnae gr. |. M. One of these should be taken at bed-time, and will generally be fol- lowed by an easy passage on the following morning. If this does not work satisfactorily, various other remedies may be substituted, amongst > W. H. Taylor, Lancet, May 3lst, 1879. PRURITUS ANI. 276 the best of which is the compound licorice powder, the rhubarb and soda mixture, or the dinner pill; the object being to find one among the many laxative preparations which, without causing pain or diarrhoea, will give an easy and natural evacuation of the bowels once every day. The use of enemata for chronic constipation should not be commenced till all other means have failed, for the reason that when once the bowel has become accustomed to this form of stimulus it will be found very difficult to discontinue its use. In some cases, however, their employment may be a necessity and they ai*e always much less harmful than purgatives. Instead of the ordinary enema of soap and water, the introduction of a hannless foreign body into the rectum will sometimes excite