PRURITUS OF THE ANAL REGION.* BY BERNARD ASMAN, M D., LOUISVILLE, KY., Professor of Diseases of Rectum, Kentucky University, Medical Department. That a more annoying, more persistent, or more intractable affection than welldefined, fully-developed pruritus of the anal region can hardly be found in the entire realm of medicine and surgery will not be denied. To a greater degree, if possible, than in any any other condition is it necessary to make an extremely careful study of the etiology of the particular case if any hope of cure, or even of benefit, is to be entertained, for upon this point, as will be presently seen, hinges the selection of the proper method of treatment. Pruritus of the anal region, as is readily inferred from the term, has for its chief symptom itching of the area involved; but the term in its full significance means much more than this it is intended to convey the idea of a true pathological condition of the skin of the affected area. There are three distinct clinical types of the disease to be recognized: 1. That in which the itching is of but recent origin and in which inflammatory changes have but just begun, the trouble being due to fissure, blind internal fistula, ulcerating hemorrhoids, or other disease. of the rectum capable of producing an irritating discharge, which almost constantly bathes or at least keeps moist the peri-anal skin. 2. The advanced or fully-developed stage of the foregoing. In this the itching is more intolerable, more constant, and the changes in the skin itself pronounced. The skin becomes thickened and more and more indurated as the result of repeated attacks of inflammation. It is thrown into folds and bleeds because of much scratching. 3. That form of pruritus which might be properly termed a disease in itself, i.e., the condition in which the trouble is not a symptom of, and has not been produced by, some disease of the rectum or surrounding structures. This is the form which some authors are pleased to style systemic pruritus, because there is no ap parent local disease to account for the trouble, and because it seems to be due directly or indirectly to some general or systemic disease, such as gout, rheumatism, lithemia, etc. It need hardly be mentioned in this connection that simple irritation of the anal region, with consequent temporary itching, does not constitute pruritus ani in the accepted sense of the term. To return to our first clinical type, that in which the itching is of but recent origin, and in which inflammatory changes in the skin have but just begun, one would readily suppose that a condition of this kind seen soon after its inception should be quite easy to cure. Compared with the other forms of the disease, such is the case, but compared with other anal diseases seen at the same stage of development quite the reverse is found to be true. A rigid and complete examination of the rectum and anal region must be made. While acute the skin around the anus for two or three inches is very red, oftentimes edematous, and frequently excoriations cover the surface. When the buttocks are held gently apart and the edges of the anus everted one or several drops of pus may be discovered. It is important to look for the pus in this way, for by the time it has reached the peri-anal skin it may be so mixed (the quantity being small) with perspiration or other moisture of the part, that it may no longer be recognizable as pus. recognizable as pus. Once found it is a clue which easily leads to the prime * Read before the Thirty-second Annual Meeting of the Mississippi Valley Medical one or more of the conditions mentioned capable of producing an irritating discharge, bathing as it must, because of the anatomy of the part, the anal canal and peri-anal skin, especially if found in an individual who is not scrupulously careful to frequently cleanse the anal region, we will quickly have the first symptom of pruritus of the first type manifesting itself. Needless to say, the longer this condition is neglected the worse it becomes, finally merging into the second type. Fortunately, the cure of the cause, especially if early in the attack, results in complete relief. This removes the irritating discharge, and the skin, not yet being badly diseased by the inflammatory processes, soon returns to the normal. The folly of attempting to cure pruritus of this kind by the application of salves, lotions, etc., is too palpable to admit of argument. Is the cause, then, found to be an ulcerating anal fissure, not involving the sphincter muscle, complete relief and cure can be given the patient by a few office treatments. After thoroughly cleansing the part and anesthetizing by injecting a betaeucain solution, the base and sides of the ulcer can be carefully trimmed away with a pair of small curved-on-the-flat scissors. Dress the wound every day until healed. Stopping the morbid discharge stops the itching. The other conditions mentioned can also, as a rule, be removed by operation with the aid of a local anesthetic. In some cases, however, and especially in those in which the diagnosis is not absolutely positive and complete, a general anesthetic should be given in order that a more satisfactory search may be made and that no vestige of the disease may escape. The following case typically illustrates this form of pruritus: Mr. G., aged thirty, bank clerk, married, good habits; was referred to me by his physician January 10, 1906, because of an intense itching of anus and peri-anal skin, which had existed several months and which had persistenly refused to yield to the application of the usual antipruritic remedies. Inspection showed a slightly increased amount of moisture on skin around anus and in anal canal. Holding the anus open with a bi-valve speculum, a small submucous fistula in the anterior wall of the bowel, beginning just above the external sphincter and leading upward for about an inch, was readily de tected. By means of local anesthesia the suppurating tract was easily eradicated, the wound healing in about ten days. The patient was instructed to keep the anal region perfectly clean and dry. The itching ceased entirely within three weeks, since which time there has been no suggestion of its return. In Type No. 2 we have a very much more serious condition with which to deal. It has its origin in the same way as No. 1, and is, in reality, simply a neglected case of the first type, having its symptoms greatly intensified, the changes in the skin, the results of the repeated attacks of inflammation, being especially marked. The skin loses its natural elasticity, becoming hard and brittle, and much thickened, the terminal nerve filaments being compressed. In cases of long standing the color changes from the bright red, as seen in the acute form, gradually assuming a dull gray or even pearly-white appearance. As co-existing conditions, which may have served as causative factors, often. times are found an hypertrophied and irritable sphincter muscle and rectal constipation. An irritable sphincter adds much to the suffering these patients have to endure, and is the direct cause of rectal constipation-a condition in which the rectum is never free from feces. This keeps up a congestion, which adds to the irritation by direct pressure and also results in the production of a great deal of flatus, which, as voided, carries with it some mucus, thus keeping the anal region moist and thereby adding to the pruritus. In the severe forms of the disease the pain and itching are more or less constant, yet subject to exacerbations intermittent in character, coming on more especially (1) after defecation; and (2) at night when the patient has become warm in bed. These attacks often become so distressing to the patient that his rest is seriously interfered with; he sleeps but little, and his general health suffers in consequence. If he is not already a neurotic he soon becomes very nervous, is unfitted for society or business; never knowing when an uncontrollable as well as unbearable seizure of itching is coming on, he becomes melancholy, hopeless, finally desperate. Manifestly, in such a case the first thing to do is to find the exciting cause and eliminate it; remembering, however, that while this is an important part of the treatment and must not be overlooked, it does not constitute the entire treatment, for in this type of pruritus we still have the diseased skin, hardened and thickened from repeated attacks of inflammation, partially excoriated from much scratching, the terminal nerve filaments compressed, diseased, and partially destroyed, to contend with. If the sphincter muscle is found to be irritable or hypertrophied it should be completely divulsed or divided. Whatever rectal disease may exist, such as hemmorrhoids, fistula, ulceration, etc., should receive the appropriate radical treatment. The bowels should be moved regularly, especial care being taken to see that the rectum is kept free from fecal accumulations. Diet and exercise must not be overlooked. Smoking and alcoholic drinks should be forbidden. Tea and coffee should be used in moderation if at all. A light diet, such as soups, bread and milk, eggs, etc., recommended. Cleanliness of the anal region is a necessity. Rest and sleep, in extreme cases, must often be artificially produced for a time, care being taken that the patient does not contract a drug habit. Lotions and applications of various kinds have been recommended in great numbers, many of which are complete failures in the majority of cases. Of the lotions one of the best is the lactate of lead, highly recommended by Miles, of London. It can be easily prepared by mixing one drachm of the liquor plumbi subacetatis with seven drachms of fresh milk. It forms a thick, creamy compound with which a piece of gauze or cotton can be saturated and placed in contact with the itching surface. In my experience the most reliable agents to release the compressed nerve filaments and to restore the diseased skin to the normal condition are monochloracetic acid and compound tincture of benzoin, used in the following way: After thoroughly cleansing and drying the affected area paint it ever very lightly with a saturated solution of monochloracetic acid, being careful not to allow the acid to touch any place except the part to be treated. Apply gauze saturated with olive oil and bandage. Inspect the part Inspect the part the following day, and if there are any points that have not been acted upon by the acid, retouch them. After four or five days the superficial layers of the epidermis that have been destroyed by the action of the acid begin to peel off, leaving a raw but healthy surface if the acid has gone deeply enough. Keep clean, dress every day, and as soon as the desquamation is complete apply compound tincture of benzoin liberally every second or third day. This can be done conveniently by means of a tooth-pick, around the end of which a small pledget of cotton has been wrapped and dipped into the benzoin. Partial relief from itching dates from the first application of the acid, and it should be complete by the time the skin has entirely healed; if it is not we are to understand that the acid has not acted deeply enough and a second application should be made and followed by treatment with the benzoin as before. The following case is illustrative of this type of the disease. Mr. E,, white, farmer, aged forty-two, presented himself for treatment in November, 1904, saying that he was a sufferer from itching piles." He had been robust and healthy all his life with the exception of the year preceding this time, during which he said he had been annoyed so much by the "itching of his piles" that he had become very nervous, had lost flesh, appetite had become poor, he could not sleep or rest at night, was almost constantly uneasy, and at times the pain and itching was almost past endurance. He said he could not work or concentrate his mind on anything, and that he had come to the conclusion that unless he could get speedy relief life was no longer desirable to him. Examination revealed large internal hemorrhoids that would protrude easily. The mucous membrane of the anal canal was harsh, rough and indurated. The skin in a radius of three inches laterally and posteriorly, and as far as the scrotum anteriorly, was thrown into folds, had lost its elasticity, pearly-white in appearance, and much thickened from inflammation, kept up by constant scratching. He was given a general anesthetic, the hemorrhoids removed by the modified excision method, and the affected skin treated with monochloracetic acid, followed by the benzoin application, as just described. The pruritus was relieved and there has been no recurrence of the trouble. The third type of pruritus ani, viz., that in which the itching and the dieased skin is not a symptom of, and has not been produced by, some form of ano-rectal disease, frequently presents features that are, indeed, puzzling. Idiopathy, as formerly taught in regard to this condition, is no longer accepted. That there must be a cause, even though it may not be evident, there can be no question. Apparently neurotics and those who have a tender skin and who perspire very freely are especially liable to this form of disease. It must not be forgotten that various parasites, especially thread worms, cause most obstinate pruritus. Of the systemic conditions with which we may find pruritus ani associated, either as a symptom or as a product of the disease in question, may be mentioned lithemia, gout and rheumatism, chronic constipation and auto-intoxication. That pruritus often depends upon the same cause that accounts for the existence of lithemia, gout or rheumatism is demonstrated by the fact that remedies which relieve these diseases benefit or relieve the co-existing pruritus. Intestinal fermentation,constipation and consequent auto-infection play a great part in many disease conditions, in none more so than in pruritus of this form. Consequently, then, in studying the etiology of obscure cases of pruritus, disturbances about the alimentary tract must be investigated and the proper remedy applied. Indeed, many cases will be benefited by thorough cleansing of the intestinal tract, followed by the use of the so-called intestinal antiseptics, to keep clean and prevent further toxemia, together with antilithic remedies in rheumatism and uricemia. The constitutional trouble, the cause of this form of pruritus, then, being attended to, there still remains the effects of the inflammatory attacks in the skin of the affected area itself to be treated. In the opinion of the writer this can be done in no better or surer way than by the use of the monochloracetic acid and benzoin, as described. 713 Fourth Avenue. (For discussion see p. 469.) PRESENT OPERATIVE NECESSITIES FOR CURE IN TUBERCULOUS ORCHITIS.* BY CHARLES E. BARNETT, M.D., The surgical cure for tuberculosis is to remove the source of infection, be it single or multiple. So it should be the surgeon's ambition to-day to make his operation a radical one, as far as possible, in tubercular infections. This is especially applicable in tubercular orchitis. In testicular tuberculosis the question arises whether it is primary or whether it is secondary to tuberculosis elsewhere in the body. This one question, along with the other organs of the uro-genital tract, has been under discussion for many years, with divergent opinions from men most competent to judge. For instance, Bryson says: "Neither in my notes nor within my recollection is there a single case where tuberculosis was primary for the body in the kidneys." Yet White, on the other hand, on account of surface infections of the ureteral orifices and trigone of the bladder, says: "That from the clinical no less than from the pathological and etiological points of view, one must con cede for the uro genitalia a primary renal infection." (Sustained by Herberg, several thousand autopsies, Israel, the Mayos and others.) Councilman believes that the epididymis and testicle are primarily invaded the most frequent in uro-genital tuberculosis. (Sustained by Delafield, Prudden, Jacobson, Lydston and others.) In three out of thirty-five cases of tuberculosis Casper found the bladder the sole seat of the disease. Kelly also reports a case. White and Martin and Bangs-Hardaway both cite authority for giving the prostate the burden of being the distributing centre, being primarily infected with tubercle. Thus it is shown that with the exception of the vesiculæ seminales (and I am not sure that they are immune1), each organ of the genito-urinary cycle has been given the credit of a primary invasion. I Delafield and Prudden say: "Usually the vesicles are secondarily invaded." * Read before the Thirty-second Annual Meeting of the Mississippi Valley Medical Association, at Hot Springs, Ark., November 6 8, 1906. The following modes of infection, either primary or secondary, within or without the body, will likely meet the more recent ideas of investigation: 1. Hematogenous distribution. (Weichselbaum, Heller, Weigert, Clado, Staltzman and others.) 2. Infection by way of lymph channels. (Koch.) 3. Infection by excretion of tubercular material through the kidneys, with or without auto-infection of same. (Kezywicke 93 per cent., Halle, Melchior, Baumgarten, Virchow and others.) 4. Infection from cohabitation in or catheterization or instrumentation from tubercular soil (Verneuil, Fournier, Morton, Mayo and others), followed by (a) tubercular prostatitis or descending, producing (6) tubercular epididymitis and orchitis, then ascending to invade (c) the vesicula seminales; ascending to the (d) prostate and bladder, then advancing up to the (e) ureter till the kidney is invaded. (Tuffier, ureter infected midway; Rokitansky, Warren and others.) Also fol lowing down the (f) urethra, infecting Cowper's glands, as well as the urethra itself. In accepting this classification, it behooves the surgeon, in operating, to remove all outgoing streams, in order to prevent a post-operative invasion of tubercle into adjacent tissue. Only a short time ago I read an article (Journal A. M. A., October 6, 1906), by Bevan, of Chicago, advocating the nonremoval of a tuberculous ureter following nephrectomy. I believe that that pro cedure is not wise, and that the vis medi FIG. 1.-Case I. Shows testes, scrotum, cords and vasa deferentia (full length). |