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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 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,i 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 per

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er

* « On Fatty Diseases of the Heart,' by R. Quain, M.D., Medico-Chirurgical Transactions, vol. xxxiii.

† • On Fatty Degeneration of the Vessels of the Brain,' Medical Gazette, New Series, vol. x., p. 229.

severance 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 endeavour 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.* If hæmorrhoidal tumours or condylomata exist, they must be removed by excision, unless the hæmorrhoids 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 highlyseasoned dishes, and to partake freely of wine and spirituous liquors, he must be restricted to a vegetable

* Chap. XVIII.

diet, and the quantity of stimuli considerably 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 bed-time, 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 thė 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 com, fort 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,

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lime-water and calomel, or the bichloride of mercury, or a saturated solution of biborate of soda, ointments of lead, zinc, 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.

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