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CHAPTER I.

IRRITATION AND ITCHING OF THE ANUS.

ITCHING at the anus is a very common affection: it is more generally a symptom of disorder or irritation in some portion of the alimentary canal than a substantive disease; but so distressing is it in many cases, that it forms the most prominent feature of the patient's ailments. It occurs more frequently at or after the meridian of life than at an earlier period, though it is occasionally met with at all ages. It is most commonly caused by the presence of ascarides in the rectum, or of other entozoa infesting some portion of the intestinal tube; by the accumulation of fæces in the rectum and colon; by the improper use of mercurial and other purgatives; irritation about the neck of the bladder and prostate gland; by derangement of the digestive organs, and a depraved condition of the excretions and secretions, particularly of the liver and kidneys. It may follow the recovery from dysentery, and very generally precedes and accompanies hemorrhoidal and other affections of the rectum. Females sometimes suffer much from pruritus ani during the period of gestation; and it not unfrequently depends on derangement, or occurs at the cessation of the menstrual function. Errors of diet, particularly the indulgence in highly-seasoned dishes and too great a quantity of wine, will produce it; unwholesome food will also have the same effect: this was illustrated in the case of a professional friend who suffered severely from this affection, induced by indulging his taste for game that had been kept till it had become completely putrid: the disease left him shortly after the shooting season was over; and the following year, being dissuaded from gratifying his appetite for the unsavory food, he was free from the affection, save on one or two

occasions when he could not refrain from partaking of some birds that were particularly high.

Itching of the anus commonly occurs in feeble and debilitated constitutions; and is sometimes accompanied by an eruption of papulæ or tubercles, which may also coexist in other parts of the body; but in the greater number of cases no eruption will be perceptible. The itching is often most distressing on getting warm in bed, and frequently prevents the patient sleeping till he is completely worn out.

When the disease is of long standing, and the patient has yielded to the strong incentive to scratch and irritate the part, the skin around the anus will become thickened and furrowed, the furrows assuming a radiated direction diverging from the centre of the anus. They vary in number and length, and, though often deep, are generally free from ulceration if due attention to cleanliness is observed: but should this have been neglected, and irritating secretions have accumulated, inflammation will be induced, followed by excoriation and ulceration.

In

In the spring of 1854, I attended a married woman, a patient at the Blenheim Street Dispensary, who suffered most severely from a pruriginous condition of the anus and vulvæ. She was the mother of several children; and when she applied to me was in the fifth month of pregnancy. From the commencement of gestation she had experienced intolerable itching around the anus and posterior part of the vulvæ, rendering her life perfectly miserable. The skin, by scratching and irritation, had become rough and indurated, and deeply fissured, but was free from ulceration. consequence of not being able to sleep at night, and her torments being but little mitigated during the day, her general health was much impaired. The treatment consisted of aperients, tonics with acids, and various local applications; a solution of the nitrate of silver affording most relief. But although by the treatment adopted her sufferings were much diminished, they did not entirely subside till after her confinement, which occurred at the proper period. Some authors think that a pruriginous state of the anus ought not to be interfered with, as it prevents the accession of more serious diseases to which the individual may be predisposed, and they instance cases in which, after the itching has been relieved by treatment, or subsided spontaneously, death has followed but they

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fail to support their views by the evidence of accurate and minute post-mortem examinations; moreover, their want of knowledge of those obscure and frequent diseases of the heart and minute vessels of the brain capable of causing sudden death, with which we have recently become acquainted through the observations and pathological researches of Dr. Quain,' Mr. Paget, and others, into changes of structure, must make us hesitate to receive such inferences as correct; even were it not, as has already been stated, that pruritus ani is more frequently a symptom or an effect of disease of structure or function in some one or other of the viscera than a purely local affection.

In the treatment of this very troublesome and frequently obstinate disease, great patience and perseverance will often be requisite, both on the part of the patient and medical attendant. By the latter it must be borne in mind that the affection is rather a symptom of constitutional derangement than a disease sui generis, therefore the first endeavor must be to ascertain the cause producing it. In females, when the menstrual function has ceased, or is about to do so, it will be most important to keep the bowels free, to attend to the secretion of the liver, kidneys, and skin, and to direct exercise in the open air to be taken daily. If ascarides in the rectum give rise to the affection, they must be dislodged by such means as are recommended in treating of the subject under the head of foreign bodies in the rectum.3 If hemorrhoidal tumors or condylomata exist, they must be removed by excision, unless the hemorrhoids are internal, in which case the ligature or concentrated nitric acid must be employed. If the digestive and assimilative functions of the patient are feeble, and the constitution is otherwise delicate, a nutritious but plain diet will be necessary, conjoined with proper exercise, and the administration of alterative, tonic, and chalybeate medicines; but if the contrary be the case, and he has been accustomed to indulge in highly-seasoned dishes, and to partake freely of wine and spirituous liquors, he must be restricted to a vegetable diet, and the quantity of the stimuli con

1 "On Fatty Diseases of the Heart," by R. Quain, M.D., Medico-Chirurgical Transactions, vol. xxxiii.

2 "On Fatty Degeneration of the Vessels of the Brain," Medical Gazette, New Series, vol. x, p. 229.

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siderably reduced, if not altogether disallowed. Various remedies have been recommended in this disease, and will be found more or less efficacious according to the circumstances of the case; among them may be mentioned the decoction and infusion of cinchona with nitric or nitro-hydrochloric acid, and the various preparations of iron the bowels must be acted on by the occasional use of purgatives. When an eruption exists on other parts of the body, five grains of the compound pill of chloride of mercury should be taken at bedtime, or the same quantity of mercury and chalk with hyoscyamus, conium, or extract of poppy; and the compound decoction of sarsaparilla two or three times a day: when the gums become tender, the quantity of mercury must be reduced, or even left off for a short time, as ptyalism to any extent must be avoided. It will be advisable to continue the remedies for a few weeks after the disease has subsided, in order to guard against a relapse.

The due attention to the functions of the skin has been insisted on, and much advantage as well as comfort will be derived from the use of the warm bath every second or third day.

The local remedies that will be found useful are lotions containing acetate of lead with wine of opium, the bicyanide of mercury in bitter-almond mixture, lime-water and calomel, or the bichloride of mercury, or a saturated solution of biborate of soda, ointments of lead, zine, nitrate of mercury, &c.; but that which will frequently be found most serviceable, is the application to the part of a solution of nitrate of silver sufficiently diluted not to produce vesication, but only to excite a slight exfoliation of the skin. I attended a gentleman connected with a City bank, who suffered most severely from this affection; he had received advice on various occasions, but had not found benefit from the medicines ordered. On making an examination, the thin skin of the anus was observed to be dry and inelastic, and intersected by slight cracks. His general health was deranged by too close application to business. I prescribed a combination of aperient and tonic medicines, and used a solution of nitrate of silver to the part on three occasions; entire relief followed, and his general health improved. He now takes more exercise, and is quite well. A very distressing and obstinate case of this affection occurred in Mrs., residing at Islington: she had suffered severely some years, and had been

attended by several medical men, but experienced no relief from the treatment adopted. The functions of the chylopoietic viscera were greatly deranged; the skin around the anus was much indurated and deeply fissured, the fissures extending within the anal margin. It was several weeks before this patient was relieved: the treatment was constitutional, with local applications of bicyanide of mercury, and to relieve the aching and spasm of the sphincter I incised that muscle on each side-Dr. Greenhalgh kindly assisting me. I could mention many cases; but the text sufficiently illustrates the nature, causes, and treatment of this annoying and troublesome affection.