Or

Ac. Carbolic ........................

M. v

Ac. Salicylic ..........................

M. XX

Eng Zinc Ovid ......................

M. i

In the chronic form of prurient an the nitrate of silver solution in from four to ten per cent. applied every second day will suffice to relieve excoriations and bring about a healthy skin. Along with these suggestions for external applications, the cause must be sought which is primarily of the most importance. Gouty or rheumatic tendencies which excite this condition must be treated.

The most common factors as causes of prurient an will be found in the digestive tract in the form of chronic indigestion, associated with an strophic or hypertrophy catarrh colitis, sigmoid, or proctorial Topical applications are only temporary in their relief as a rule, when the underlying cause in the digestive tract remains uncured Irrigation of Kramer as recommended for hypertrophy catarrh colitis will be found most satisfactory in the treatment of these cases. Rhubarb and soda should be prescribed to regulate the bowels and improve the digestive tract, combined with tonics when indicated.

In view of the fact that many workers in rectal diseases attribute the causes of prurient an to disease of the nerves in the per-anal skin, it seems that it is necessary to give the surgical treatment instituted by some of these authors.

Sir Charles Ball recommends dividing the sensory nerves supplying the affected area, under a general anesthetic in the following way: On either side of the anus an elliptical incision is made about one-half to three-fourths of an inch from the margin, which is begun on either side of the perinea rape and continued around the anus to the coccyx rape The ends of these elliptical incisions should not meet anterior or posterior but should be separated at least three-fourths of an inch. The incisions are made deep enough to reach into the subcutaneous tissue. On both sides, the skin is separated by blunt pointed scissors from the underlying tissue for one inch on the peripheral side, and to the subcutaneous junction on the anal side, which should also extend beneath the underlying flaps of the perineum anterior and posterior In this manner all the sensory nerves supplying the parts are divided. When this is completed the flaps are allowed to fall back in place and their edges stitched back with interrupted catgut sutures and a compress applied. The dressing should be renewed twice in twenty-four hours after the wound is sponged off with a weak solution of dichloride The patient should be kept in bed and the bowels confined until the fifth or sixth day. Union of the parts should take place within this time and relief from the itching procured.

Martin modifies Ball's operation by interrupting each of the lateral incisions at the middle, in that manner leaving a connecting bridge of tissue between the internal and external flaps.

Rouse modifies Ball's operation by making six or eight linear incisions through the skin into the subcutaneous connective tissue, beginning at a point outside of the area of irritation, follow the course of the radii of a circle with its center in the anal canal.

Then the skin flaps lying between the adjacent radii are undercut until the whole affected area is undermined and separated from the overlying skin. In this mane he divides all of the nerve filaments. When the dissection is found difficult by this procedure every alternate flap may be loosened at the anal margin so as to permit more room and dissected outward toward the periphery. The parts are replaced and sutured as a final step in his technique. The objections cited against this operation are that while the purpose is the division of the nerve filaments, the blood supply in many instances is also cut off, resulting in infection of the skin flaps.

The X-Ray and High Frequency Currents have not proved of success in the treatment of this disease and its use can hardly be advocated as a general treatment, but exceptional cases may be benefited.