PRURITUS ANI is on of the most distressing affections encountered in the sphere of proctology. A discussion of its definition is superfluous: the particular factor of interest to the sufferer as well as to the physician in charge of the case concerns its etiology.
The divergence of views on the etiology is evinced, on the one hand, by an authority who reports over 100 different causative factors, and, on the other hand, by he highly skillful and scientific group at St. Marks Hospital in London who dismiss the condition with a statement that if most causes are eliminated the condition will be remedied by simple cleansing measures. On my visit to St. Marks Hospital last summer it was interesting was the recommendation of large amounts of soap and water applied frequently.
However, the position taken by the men in this outstanding rectal institution is understood when one sees the rectum and the adjacent structures are investigated and eradicated. In the greater number of cases local rectal pathology was believed to be the cause; thus proctitis, fissures fistulas, haemorrhoids, cryptitis, papillitis, ulcerations, skin tags, tumors of the rectum, and mucous polyps all received appropriate attention.
Chemical factors should be recalled-abnormal secretion from the colon and rectum; abnormal number of stools (either from local condition or from laxatives); the effect of irritating foods, drinks and condiments; hypermotility from neurosis or due to deficient gastric secretion with the resultant diarrhoea of achylia, and colitis of the various types; allergy and anaphylaxis parasitic invasion of the colon-not only the Entameba histolytica, but worms of all types from oxyuris vermicularis to the tenia.
Primary eczema about the rectum; thrombitis due to drugs, as injected haemorrhoids, must be considered. From a mechanical standpoint, constipation with dry, hard stools, hard concretions, obstruction; malignant or hard stools, hard concretions, obstructions; malignant or benign growths; congestion; disease of the female generative rectal secretion due to wrinkling of the skin or due to hypertrophy; ulceration from any cause within the rectum, among which may be enumerated old fistula and fissure tracts; operated haemorrhoids; hypertrophied crypts; hypertrophied papillae; and senile skin changes all must be bone in mind.
Along with this there must be a study of the blood sugar to determine if a hyperglycemia is present. Fungi and mycotic organism; scabies and pediculosis; systemic diseases besides diabetes and liver diseases; anaemia; exophthalmic goitre menopause and pregnancy; genito-urinary diseases; strictures, syphilis; and systemic neuroses must be excluded. Lastly, idiopathic or essential pruritus ani, the diagnosis of which can be made only after every other known cause has been eliminated.
Considering previously mentioned causal factors, it can readily be seen in how many directions the treatment of the condition may be carried. Over a long period of time the bacterial causes-streptococcus, staphylococcus, enterococcus and colon bacteria-were said to be the major factors, and vaccine treatments were used with much enthusiasm. The disciples who believe that bacterial vaccines increase opposition is all that is required, have been explaining diseases thus cured as due to this stimulation, and that these various forms of vaccine act as nonspecific proteins; the stimulation of the protein-spitting ferments being the only element necessary to eliminate the poisonous proteins within the body.
Diathermy has had its advocates, as well as the use of the roentgen ray but users of that form of treatment must be particularly careful that no previous x-ray has been given, as Yeomans has exhibited one or two serious ulcerations which have occurred by superimposing one series of doses upon another. Quinine urea hydrochloride also had a vogue for a period, but the injection caused a good deal of pain. This, however, can be eliminated by a previous injection of 1 or 2 per cent be solution of procain. Haines advocates subcutaneous injections of dilute hydrochloric acid in 1-5000 to 1-2000 strength preceded by fifteen to thirty cubic centimeters of the dilute hydrochloric acid injected and repeated at weekly intervals for about four treatments.
His theory is that acid kills the organisms or causes their environments to be uninhabitable; it does not destroy the nerve endings. Hospitalization for one day is advisable in these cases. Many cases are greatly aided by the injection of alcohol into the affected area: one large clinic stated that they cured 95 per cent of their cases by the use of alcohol. The solution used is 40 per cent of their cases by the use of alcohol. The solution used is 40 per cent ethyl alcohol, and their method is to inject the solution under the skin as in local infiltrating anesthesia. The entire injection can easily be made through one needle puncture, and it is better to give the entire injection through one puncture than to make multiple punctures, for with each break injection may be admitted, and with this is the danger of slough.
Twenty cubic centimeters of the solution are injected, care being taken that the solution goes externally to the sphincter muscles immediately beneath the skin lest the sphincter be injured, which may cause incontinence. No other operative procedure should be done at the same time. Should haemorrhoids, fistula or fissure be present, they should be removed at a previous operation. This clinic stresses the factor of abscesses, inflammation and sloughing following, and states that the patient should be informed of these possibilities; noting at some length the necessity for applying moist, warm dressings immediately after the operation again noting that anesthesia may allow burning to take place.
This, however, is a technic concerning which I have not become extremely enthusiastic, it having been my own practice to use the alcohol as an injection directly into the skin. Pure, undenatured alcohol is injected with a small hypodermic using a fine, short needle. The needle is plunged vertically into the skin, and two to four drops of the alcohol deposited intradermally at each puncture; the punctures being placed about a quarter of an inch apart, and made down to within a quarter of an inch of the anal margin.
Skin sloughs may follow, but in my own experience, despite this unpleasant complication, the relief of symptoms has been so great that patients have returned in cases of relapse and have applied for further injections. It certainly checks the itching promptly. Yeomans has used a solution of benacol consisting of five parts each of paramino benzyl ethanol benzoate phenymenthol in ninety parts of rectified sweet almond oil. The technic of this injection is as follows.
The peri-anal section is prepared with tincture of iodine: a glass hypodermic syringes of two cubic centimeters capacity fitted with a 22 gauge needle 12 inches in length is filled with benacol which is injected slowly beneath the skin, and mucocutaneous injections of the peri-anal region are distributed as evenly as possible fanwise from the anal verge. It is essential to inject the solution just beneath and not into the skin to prevent sloughing. The amount injected at one time in a single quadrant is two cubic centimeters, beginning with the quadrant in which the itching is most intense.
Treatments are repeated at intervals of two to three days until the entire peri-anal region has been injected. The as in necessary until the itching is entirely relieved. The same area may be re-injected at this interval as often as is necessary until the itching is entirely relieved. No preliminary anesthesia is necessary with this method, the injections as a rule being painless. (Contrast with the alcohol and hydrochloric acid injections.).
Five per cent phenol in oil has been used. Ionization with antiseptics has been applied, but has not been satisfactory.
The technic of the surgery with the undercutting operation has been used at times, but even in this operation, which requires the patient to be in the hospital, there is apt to be a return.
From. St. Marks Hospital has come what, to my mind, is the most satisfactory solution for use by hypodermic-nupercaine 2 percent, phenol 1 per cent, benzyl alcohol 1 per cent in almond oil. Gabriel is the originator of the solution, the very extensive use of which I observed when in London last summer, and during the past winter I have used it, and feel that it is eminently satisfactory, in fact the ideal treatment. This solution is about to be brought open the market here by Ciba, and by application to them it can be procured at the present time. The exact technic is as follows:.
“Nupercaine, Ciba base with phenol and benzyl alcohol in oil has been prepared in accordance with the suggestion of the British proctologist, Gabriel. Utilized first for treatment of pruritus ani, later work in America, especially by Frankfeldt, has established the value of the preparation in anal fissure and ulcer, rectal neuroses, and for partial or complete anesthesia prior to operative treatment of short fistulous tracts, internal operative treatment of short fistulous tracts, internal haemorrhoids and external thrombotic piles. The out haemorrhoids and external thrombotic piles.
The out standing advantages of nupercaine, “Ciba base with phenol and benzyl alcohol consist in (a) the unusually of pain following the injection, and, (b) the unusually prolonged duration of the anesthesia which it produces. Being a concentrated solution, the preparation should be used only in strict accordance with directions. Injections should not be made into an infected region, and the solution should be introduced well beneath, and the solution should be introduced well beneath the skin; never intradermally. Ten cubic centimeters of nupercaine, Ciba base with phenol and benzyl alcohol at the first treatment four different punctures in the posterior half of the rectal circle.
A week later, five cubic centimeters are injected in the right anterior and the left anterior quadrants. Cracks or fissures are swabbed with silver nitrate, balsam of Peru, or a simple lead lotion applied to the irritated peri-anal skin. A feeling of numbness develops which lasts several weeks, so that sufficient timed is afforded for the treatment of any allied pathology. An average cases requires three doses (ten, five, five cubic centimeters) to effect cure. It is important to make these injections subcutaneous and not intradermal, otherwise a slough is liable to result, but if such were to occur it would be painless and heal without any discomfort to the patient”.
I have omitted from this discussion the standard anti pruritic solutions and ointments, formulas for which are readily procured from any textbook. The effort has been to cover, in a practical way, the etiologic factors which must be entirely eliminated before instituting treatment; then to present as applicable and worthy of consideration, the alcohol treatment, stressing the dangers of sloughing; also, to present the technic of the use of he Gabriel solution as eminently satisfactory in overcoming the condition in that group of cases which are not cured by the elimination of definite systemic causes or evident pathology in the rectum and the adjacent tissues.