PRURITUS ANI. 137
unendurable by it. In fact, one very nervous invalid told
me that unless he had obtained relief, he believed that he
should have gone out of his mind. It is very intractable,
but I am confident that it is always curable if the patient
will strictly, patiently, and persistently follow the advice of
his medical attendant.
The disorder is frequently induced, or at all events kept
up, by habits of too free eating and drinking, and its success-
ful treatment, therefore, calls for a considerable amount of
self-denial on the part of the patient ; and thus it often hap-
pens that as soon as the sufferer gets relieved he forgets all
his prudent resolutions and relapses into his old way of life
— a step which is pretty certain to result in the return of his
enemy in full force. He then usually blames his doctor,
very rarely himself, and either gives up in despair all hope
of cure, or seeks new advice, so that the affection comes to
be considered as not only an exceedingly troublesome one,
but almost incurable. I can truly state that I have rarely,
if ever, failed to cure a patient who adhered rigidly to my
directions ; and when a person, the subject of bad pruritus,
comes to me, I always say, " Unless you intend to conform
most religiously to my directions, as long as I think necess-
ary, I cannot cure you, and I had much rather that you con-
sulted some other surgeon." Although, as I have said, free
living often induces pruritus, I have met with many cases in
very abstemious persons ; I have seen a most ascetic clergy-
man suffer dreadfully, and I have had under my care a lady
who nearly all her life has been a total abstainer from alco-
hol, and is a remarkably small eater, yet she has been
quite a martyr to this complaint.
The irritation, in the majority of cases, is worse at night,
especially when the patient gets warm in bed, so that often
the greater part of the night is rendered sleepless and inex-
pressibly wretched; towards the morning, irritable and worn
out, he falls off into a fitful slumber, from which he often
awakens himself by scratching ; this, of course, makes the
part more or less raw, and materially adds to his discomfort
in the daytime. I need scarcely say that the more the suf-
ferer scratches the worse he makes himself, although it is
very difficult indeed to avoid seeking the temporary relief it
affords. Many persons have told me they would infinitely
prefer decided pain to the dreadful and constant itching
they have to endure, which really, after a time, becomes pain
of a most sickening character. Excitable people are often
138 PRURITUS ANT.
greatly troubled in the day as well as at night, the itching
setting in badly after exercise or on leaving the cold air and
coming into a warm room.
Doubtless there are many cases of pruritus for which we
are unable to assign any cause, and it may then be consid-
ered as a pure neurosis ; but usually it is possible to dis-
cover some reason for the irritation in derangement of other
organs. The secauses may be mentioned — liver affections,
internal haemorrhoids, constipation, anything causing press-
ure upon the hsemorrhoidal veins so as to retard the return
of blood from the rectum, disorders of the stomach induced
by errors in diet, latent gout, uterine diseases, and we must
not forget parasites, as vegetable growths, pediculi similar to
those found on the pubes, and ascarides.
It is generally stated that there is a very little alteration
in the aspect of the part affected, and that nothing is to be
observed beyond a roughened, thickened and more rugose
state of the skin just around the anus. This I think is by
no means usually the case; sometimes there is a distinctly
eczematous rash, the part being always moist from exuda-
tion; at others there is a dry, rugose condition, with bright
redness consequent upon scratching; occasionally there are
a quantity of minute scales to be seen, forming irregular
rings; often cracks are seen radiating from the anus, and
even extending up to the sacrum; but what I consider the
characteristic condition — which may ahyays be noticed
when the disease is severe, and has lasted for any length of
time — is the loss of the natural pigment of the part. To
such an extent does this often obtain, that patches around
the anus, extending backward as far as the sacrum and for-
ward to the scrotum, are of a dull, dead white, the skin
looking more like very white parchment than natural integu-
ment, and if you pinch it up you will feel that it has lost its
normal elasticity. I have seen a similar condition induced
by genital pruritus in women.
When considering a case as to the question of treatment,
it is always important to discover the cause of the irritation;
particular articles of diet or drink affect some persons in a
remarkable manner. I once, had a patient who invariably
got an attack of pruritus from eating lobster or crab, and of
these shellfish he was inordinately fond, but rarely dared to
indulge his taste. I have seen a similar result from eating
salmon. Another of my patients was sure to suffer if he
drank any quantity of champagne or ale, and the irritation.
PRURITUS ANI. 139
once started was very difficult to arrest. There is but little
doubt that excess at table, combined with a want of active
exercise,are not only a predisposing but also an exciting cause.
Excessive smoking is another excitant of the disorder; I
have seen several instances (where patients had a tendency
to the malady) of over-indulgence in smoking being fol-
lowed immediately by an attack of pruritus.
Spare no pains to investigate closely the habits of your
patient. Stout, plethoric people should be put on a rather
low diet; they should avoid all rich and highly seasoned
dishes, eat but little meat, and take fish, poultry, vegetables,
and ripe fruits. Interdict both beer and spirits, and restrict
the drinking to a little light sherry or claret and Vichy or
Seltzer water. Coffee should be given up, weak tea or
cocoa being taken at breakfast. Enjoin a walk of three or
four miles daily, and, if possible, at such a speed as to
induce slight perspiration; let the patient take a sponge bath
every morning, a warm or Turkish bath once in the week,
and every night when retiring to bed wash the anus and
parts around with warm water and tar or Castile soap. If
the bowels are at all confined the following prescription will
be found beneficial:
^. Magnes Sulph 3j
Magnes. Carb. pond gr. v
Vini Colchici mv
Syrupi Sennae 3 j
Tinct. Cardam. comp 3 ss
Ex. Inf. Chiratae § j M.
Twice or thrice in the day.
And I also often order —
]^ . Pil. Plummer gr. ij
Til. Rhei. comp gr. iij M.
To be taken every other night for a week.
The mineral waters of Carlsbad, Friedrichshall, Vichy,
Hunyadi Janos, Pullna, etc., are good remedies, and I fre-
quently employ them.
After the washing at night let the patient apply this oint-
ment freely:
3 . Hydrarg. Subchlor gr. x
Ung. Sambuci 3 j M.
I40 PRURITUS ANI.
Or this lotion, which, is very efficacious in allaying irrita-
tion : —
^ . Sodse Biboratis 3 ij
Morphias Hydrochlor gr. xvj
Acidi Hydrocyanic, dil | ss
Glycerinse | ij
Aquae ad § viij. M.
Dab the part frequently. A chloroform pomade made
thus is often useful: —
^ . Chloroform 3 ij
Glycerinae | ss
Ung. Sambuci | iss. M.
A lotion of borax with colchicum, a saturated solution of
borax, the Ung. Boracis c. Vaseline (gr. x, ad 3 j), the sul-
phide of calcium internally and externally, as recommended
by Hebra, a pap of Tenax, are other remedies that may be
tried. Sir Benjamin Brodie had much success from the
white precipitate ointment. The following prescription of
the late Mr. Startin has been of great service to many
patients suffering from eczema. I have seen a bad case
cured in forty-eight hours by its application alone: —
5" Liquoris Carbonis Detergent.
(Wright's) Glycerinae aa. . . . | j
Zinci Oxidi, Pulv.
Calamin. prep aa . . . . | ss
Pulv. Sulph. precip 3 ss
Aquae purae ad | vj. M.
The part affected to be painted thickly over once or twice
daily and allowed to dry. Lastly, I must not omit to men-
tion carbolic acid, with glycerine or water, as being very
useful, and also prophylactic, after other treatment has suc-
ceeded.
All remedies may for a time be disappointing, and in
long-standing cases you must be prepared to alter your pre-
scriptions until you find what best suits your patient. In
old and feeble persons the combination of the sulphates of
iron and magnesia with dilute sulphuric acid and infusion
of quassia often does good; with it I have cured a number
of elderly people whose lives were embittered by long con-
tinued itching. Often in them the parts are quite raw, and
PRURITUS ANI. 141
discharge an ichorous irritating fluid, The tonic and laxa-
tive mixture above mentioned, and the borax lotion, with
great attention to washing the part with warm water and
Castile soap, have usually been followed with great benefit
and ultimate cure.
When you have made up your mlhd that the essence of
the disease is in the nervous system, as I think it often is,
particularly in spare and delicate, excitable people, you
should give arsenic and quinine freely, and be prepared to
push them to their physiological effect. They may be taken
separately or combined. I have rarely failed to cure this
class of cases by pereverence in these remedies; at the same
time, of course, using local means to allay irritation. In
obstinate, old-standing cases I usually commence the treat-
ment by rubbing the parts thoroughly with a solution of
nitrate of silver, 3ij to the ounce; this softens the skin and
induces a more healthy action and secretion. At times I
have found Condy's fluid, undiluted, useful for the same
purpose; it should be applied twice or oftener in the week.
The disorder is not, by any means, so common in women
as in men, nor is it frequently met with in young persons ;
but one of the most obstinate cases I ever had occurred in
a delicate lad of seventeen. There did not appear to be any
ascertainable cause for the irritation, and he was eventually
cured by Liquor Potassae Arsenitis in full doses and cod-
liver oil. I had once a very intractable case in a man nearly
eighty years of age, who was an inmate of the Bookbinders'
Almshouses at Kingsland; it resisted all remedies for some
time, but eventually yielded to arsenic internally and the
strong caustic solution frequently applied. In women the
uterine functions should be attended to; and I have fre-
quently found the citrate of iron, quinine, and strychnine
very advantageous.
I have met with a good many examples of latent gout as a
cause of pruritus ani.
A gentleman was under my care some time ago who had
often suffered from pruritus, and always got rid of it when
gout attacked him, and he was free for some time afterwards.
Here diet is a most important element in the treatment. I
think the irritation is best allayed by a strong solution of
bicarbonate or bisulphate of soda frequently applied in a
poultice. I have formed a good opinion of the usefulness
of lithia water and the effervescing citrate of lithia. In some
cases, where the irritation is very severe, colchicum with
142 PRURITUS ANI.
alkalies answers best, but if it can be managed, a course of
waters at Baden-Baden, Ems, or Carlsbad, will be found
most beneficial.
I have a very excitable, nervous patient who frequently
gets an attack of pruritus when he is mentally overworked
or irritated, and in this and similar cases I have found the
bromide of potassium very advantageous, and I have com-
bined with this ten or fifteen grains of the hydrate of chloral,
This mixture taken at bedtime generally ensures a fair night.
An extended experience in this class of cases has induced
me to think most highly of the bromide of potassium and
chloral in combination. In alternation with the chloral I
have seen great advantage result from the Succus Conii in
full doses (one to two drachms given three times in the day);
to this may be added cod-liver oil after meals, by which
means I think you may repair nerve-tissue and induce a
more regular distribution of nerve-force. I am fully con-
vinced that the more you treat pruritus ani as a general dis-
ease the more successful you will be; the difficulty in curing
it has arisen in great measure from its having been consid-
ered as merely a local affection, and only local means having
been applied for its relief.
In the treatment of pruritus ani it is well to avoid the
internal administration of opium in any form; you may pro-
cure a night's rest by its use, but you pay dearly for it after-
wards, in an increase of the disorder. When the irritation
is so great that the patient is quite worn out for w^ant of
rest, I have for years past recommended the introduction
into the anus at bedtime of a bone plug, shaped like the
nipple of an infant's feeding-bottle, with a circular shield to
prevent it from slipping into the bowel; the nipple should be
about an inch and a half in length and as thick as the end
of the forefinger. This is most efficient in preventing the
nocturnal itching; a good night's rest is almost sure to result
from its use, but I advise it to be worn only every other
night. I presume that it benefits by exercising pressure
upon the venous plexus and filaments of nerves close to the
anus. The idea of this plug occurred to me from several of
my patients telling me that the only way they could obtain
relief and sleep, when the itching was very bad, was by
introducing the end of the forefinger into the anus, and
making pressure; this instantly arrested the irritation.
When pruritus is accompanied by internal haemorrhoids,
their removal almost always cures the itching; this result
PRURITUS ANI. 143
was well shown ii> a very bad case operated upon by me in
the practice of Mr. Gervis, of Haverstock Hill. The irrita-
tion had been present for a long while, and it had resisted
all kinds of treatment, but yielded when the piles were got
rid of.
Pruritus caused by a parasitic vegetable growth is readily
cured by the application of sulphur ointment; or, what is
much cleaner, and equally efficacious, a lotion of sulphurous
acid of the strength of one part to six of water.
I had soma time ago, in an adult, a very obstinate case of
anal irritation, caused by ascarides. I really did not expect
these to be the origin of the malady, but I happened to see
one of the worms just at the orifice; a brisk purge, and a
few injections of solution of iron freed the patient of the
parasites and the pruritus also. It always well to bear in
mind the possibility of these causes of the disorder.
CHAPTER XV.
FISSURE AND PAINFUL IRRITABLE ULCER OF THE RECTUM.
This is an excessively painful and by no means uncommon
affection; it is more frequently found in women than in
men, although not rare in the latter. I have seen fissure in
a baby in arms, and in a old woman of eighty, in whom it
was associated with ^n impaction. By far the most usual
position of fissure is dorsal or nearly dorsal, although it may
be anterior or lateral. It may be brought about by an
injury or tearing of the mucous membrane at the verge of
the anus; it may therefore be caused by straining, or by the
passage of very dry, hard motions; sometimes it follows
severe diarrhoea; it is frequently the sequel of a confinement,
and the accompaniment, and occasional result, of polypus.
The origin of many fissures is syphilis.
As a rule patients suffering from fissure of the rectum
imagine that their symptoms are due to haemorrhoids; they
tell you that they have a discharge of blood and matter, a
swelling outside the bowel, and pain at stool, and they
believe they have piles. Unfortunately, not infrequently
the medical attendant is satisfied with the patient's diagnosis,
and treats the case as one of external haemorrhoids*
144 FISSURE AND PAINFUL
I should say generally that when a patient complains of
great pain on defecation, it is not piles that he is suffering
from, and certainly not uncomplicated piles.
In fissure the pain on the bowels acting is more or less
acute; some describe it as like tearing open a wound, and
doubtless it is of very excruciating character. I have known
patients who for hours could not bear to stir from one posi-
tion, the least movement causing an exacerbation of the
pain. This agony induces the sufferer to postpone reUeving
the bowels as long as possible, the result being that the
motion becomes desiccated and hardened, and inflicts more
grievous pain when at last it has to be discharged. After
action of the bowels, the pain may in a short time entirely
cease, and not return at all until another evacuation takes
place, but often it continues very severe and of a burning
character, or it is of a dull, heavy character, and accom-
panied by throbbing, which lasts for hours, sometimes even
all day, so that the patient is obliged to lie down, and is
utterly incapable of attending to any business. In some
instances the pain does not set in until a quarter or half an
hour after the bowels have acted.
In children and young persons, unless a polypus com-
plicates the fissure, I think it is almost always curable without
operation. I have had many cases resembling the following.
A child, aet. 4^, admitted into St. Mark's, September,
1867. For twelve months or more he has been subject to
procidentia every time his bowels acted; he is usually rather
constipated. About five or six months ago he began to
suffer pain, which lasted for hours after the bowels had been
relieved; this was so severe that he screamed and rolled
about in his bed; he often passed a little blood; the pain
was much aggravated when he was costive. On an injection
being given, the rectum came down, and a very distinct
fissure with a papillary growth at its commencement was
seen. There was no polypus in the bowel; Ung. Zinci with
extract of belladonna and opium was ordered to be used
night and morning, and confection of senna with sulphur to
be taken to keep the bowels gently acting. This prescription
afforded immediate relief; in three weeks the ulcer was
healed and the child perfectly cured.
In children suffering from hereditary syphilis, numerous
small cracks round the anus are common, and they cause
much pain. Mercurial applications and extreme cleanli-
ness soon cure them, but they will return from time to time
IRRITABLE ULCER OF THE RECTUM. 145
unless anti-syphilitic medicines be taken for a lengthened
period.
Fissure, although really so simple a matter, and its cure
generally so easy, wears out the patient's health and
strength in a remarkable manner; the constant pain and
irritation to the nervous system are more than most persons
can bear; I have frequently seen women suffering from small
anal ulcer, who thought they must have cancer, in consequence
of their extreme illness and pain. What under these circum-
stances is very extraordinary is the length of time people go
on enduring the malady without having anything done for
it. It is not an uncommon thing for one to see fissures of
many years' duration, especially in young women, who,
through delicacy of feeling, often conceal rectal affections.
It is common for fissures to heal for a time and then
break out again, so patients are apt to think a perfect cure
will result, and defer proper treatment.
The usual position on the side is the best for making an
examination. Let the patient raise the upper buttock with
the hand, then with your fore-finger and thumb gently open
the anus, at the same moment telling the patient to strain
down; you will then be able to see, just within the orifice, an
elongated, club-shaped ulcer; the floor of it may be very red
and inflamed, or, if the ulcer is of long standing, of a grey-
ish color with the edges well defined and hard.
Frequently the sight of the fissure is marked externally
by a small clavate papilla or minute muco-cutaneous poly-
poid growth; this must not be confounded with ordinary
polypus, and it is not the cause of the fissure, but the result
of the local irritation and inflammation which have been
going on. Sometimes the situation of the fissure is indica-
ted by an inflamed and swollen piece of skin, and in this
case ulceration through the portion of the integurr^ent not
infrequently occurs, and a small but extremely painful fistula
results. In such a case very probably a small abscess had
formed just above the external sphincter, and had burrowed
under it, making in time a complete fistula. These small
abscesses are very painful. It occurred to me to observe
this in the wife of a medical man. When I first examined
her I found she had well-marked fissure and an inflamed
piece of skin close to the anus. I predicted that the ulcer-
ation would perforate this, and so it did, for in- about ten
days, when I went to operate upon her, I found a small
fistula had formed.
146 FISSURE AND PAINFUL
Occasionally, on proceeding to examine a patient, the first
thing you see is the small club-shaped papilla I have already
mentioned protruding from the anus; you may then be certain
that an ulcer exists. I may here mention that when operat-
ing, this growth ought to be snipped off, or the case may not
do well, as it falls down into the wound and retards or quite
prevents healing.
Fissure is very commonly associated with uterine displace-
ment. I have stated that of)erations upon haemorrhoids
under similar conditions are not satisfactory; the same
observation applies with quite as much truth to fissure and
uterine disease. I have many times had reasons to repent
interfering with these cases. The successful treatment of
the uterine disorder may be sufficient to cure the fissure (if
no polypus exists), or at all events the ulcer will afterwards
yield to local applications and general treatment. If the
fissure should be benefited by operation, as long as the
uterine malady exists there will be a constant danger of a
relapse taking place. The most common forms of uterine
displacement in connection with fissure are, according to
my experience, anteversion and retroversion, and associated
with these I have frequently observed affections of the blad-
der, chronic cystitis, and spasmodic pains in micturition.
When you find these three disorders united, depend upon it
you will have a case that will call for all your skill and
patience to bring to a successful issue.
Gelatinous and fibrous polypi are not at all uncommon
complications of fissure. The polypus is usually situated at
the upper or internal end of the fissure, but it may be on the
opposite side of the rectum. Here is a case:
Mary G ; aet. 47,. was admitted into St. Mark's, April,
187 1. She had a well-marked and very painful fissure near
the anus. There was no polypus to be seen, but on passing
my finger into the rectum I found a pedunculated fleshy
polypus on the opposite side of the bowel to that on which
the fissure was situated. I am quite confident that had I
incised the fissure and left the polypus this patient would
not have recovered.
If you do not remove a polypus at the time you divide
the ulcer, failure is certain to result, as I have myself seen
many times.
If the fissure is of recent origin it may often be cured
without operation, especially if it be situated anteriorly. In
women this can almost certainly be accomplished. Of all
IRRITABLE ULCER OF THE RECTUM. 147
the varieties of fissure the syphilitic is most amenable to.
general treatment; when of syphilitic origin they are often
multiple. I have noticed three distinct, mell-marked fissures
in one patient. I have seen, in the practice of my colleagues
at St. Mark's, many instances of multiple fissure. I may
here mention that if you are obliged to operate upon a
multiple fissure one incision through the sphincter will be
sufficient.
Now as to the treatment. In all cases, rest in the recum-
bent position should, as much as possible, be adopted.
Mild laxatives should be given, not to purge, but to keep
the bowels acting once daily; this may sometimes be effected
by diet alone. The domestic remedy of figs soaked in sweet
oil, or onions and milk at bedtime, may be sufficient. I
often order a combination of equal parts of the confection
of sulphur and confection of senna; small doses of sulphate
of magnesia or sulphate of potash, half a tumbler of Pullna or
Friedrichshall water taken in the morning fasting, the com-
pound liquorice powder of the German pharmacopoeia, and the