LONDON, MAY I945

POST-GRADUATE MEDICAL JOURNALA Review onPRURITUS ANI

By G. 0. CHAMBERS, F.R.C.S.A/Assist. Surg. and in charge Proctology Clinic,West London Hosp.; late Clin. Asst. St. Mark'sHosp.; Visiting Surg., H.M. Prison, WormwoodScrubs Hosp.; Cons. Surg., Free French ForcesAnal irritation, or pruritus ani, is a very common

complaint. It is, perhaps, more frequently metwith in men than in women. No age is exempt,although it is relatively uncommon in youngadults. Children are affected in association withthread-worms, or during an attack of eczema withan underlying allergic diathesis.There is often a seasonable variation, the com-

plaint being more frequent in the warmer monthsthan in winter.

Pruritus has always a local origin.-In manycases an abnormal constitutional condition, withaltered blood concentration, and an emotional orhighly nervous temperament, may predispose.

It is characterised by an intense itching orburning sensation, usually of sudden onset, begin-ning near the anal margin and spreading peri-pherally over the buttocks and perineum. Itfrequently lasts several days. The attack oftenstarts at night, as soon as the patient has settledin bed and become warm and comfortable.The irritation persists, and sleep is rendered

impossible. Later, it may develop into paroxysmsof great severity, and cause marked impairment inhealth both physical and mental.

In early and mild cases no skin changes may bevisible, though slight redness and superficialexcoriation from scratching are often present. Inchronic and more severe cases the skin undergoesmarked changes. Thickening, corrugation, fis-sures, rugae, and discharge from secondary infec-tion, form the typical picture. Most of thesechanges are due to the effects of constant scratch-ing which make treatment more prolonged anddifficult.The essential cause of pruritus may be considered

as a local focus of irritation producing stimulationof terminal nerve-endings from oedema andaltered tissue tension in the skin.

It has been observed by Macleod and Muende,'that the dermal lymph passes between fibrousbundles, epithelial and fat cells, in the tissue spacesand that there are comparatively few endotheliallined lymphatic vessels. Researches by Key andRetzius have demonstrated that the lymphcirculates in the epidermis-passing in at the

apices of the papillae and oozing back into thecorium at the interpapillary processes.

In pruritus, proliferative changes occur in theskin mainly affecting the prickle cell layer. Swel-ling and thickening of these cells are seen. In thecorium there is dilatation of the subpapillary andmid-dermal venous plexuses. Oedema, lymphaticstagnation, and capillary dilatation are presentthroughout the area.These skin changes have been described by

Riddoch,2 who stresses the importance of oedemaas a result of stasis in the external haemorrhoidalvenous plexus.He suggests that this may be the cause of

idiopathic pruritus. In cases where internalhaemorrhoids may be present, treatment by injec-tion removes the back-pressure effects of localcongestion, relieves the stasis, and cures thepruritis. It is possible that these subcuticularchanges, associated with oedema resulting fromlocal stasis, may explain most early cases ofpruritus ani.

Theories regarding the pruritic stimulus.Histologically, it may be recalled that, among

the principal cutaneous receptors, there are freenerve-endings terminating within the cells of theprickle layer.There are, also, other end-organs, such as the

basket-endings at the root of hair follicles.Any change of tissue tension around these

receptors will be passed on as an afferent stimulusby each.

Other end-organs, such as Meissner's tactilecorpuscles and Krause's end-bulbs, come into thepicture as the stimulus continues in persistanceand chronicity.A slight rise in temperature, a pull on a hair,

or sudden drop in tissue tension, as when lyingdown at night, may provoke the stimulus.The impulse passes by way of medullated fibres

through the cutaneous branches, chiefly inferiorhaemorrhoidal and perineal bran-ch of the 4thsacral nerves, to the posterior grey cornua in thespinal cord. Thence by the spino-thalamic tractto the thalamus, and, finally, by cortical fibresto the grey cerebral cortex to be interpreted as thecutaneous sensation known as itching.

According to Livingston,3 this sensation isthought to be derived from some combination ofthe four primary modalities of cutaneous sensi-bility-touch, pain, heat, and cold. Each issubserved by a specific receptor to transmit onlyone kind of impulse.The theory implies that pain is subserved by

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152 POST-GRADUATE MEDICAL JOURNAL May, I945undifferentiated type of nerve-endings; cold byKrause's end-bulbs; heat by the corpuscles ofRuffini and Golgi-Mazzoni; touch by Merkel'sdiscs, and basket-endings of the hair follicles.

Zotterman's observations, regarding sensorystimuli, hold that a central inhibitory effect isexerted on "protopathic" fibres by "epicritic"fibres within the spinal cord.He subscribes to Foerster's view upon the

sensations of tickling and itching. In this itseems that the fast impulses travelling up theposterior columns inhibit the central effect of thelater arriving impulses; the less the large fastfibres are stimiilated, the more intense become thetickling and itching sensations elicited by slowimpulses.Rubbing an itching area is an instinctive reac-

tion giving some degree of relief. It belongs tothe group of instinctive reactions such as squeezingthe hands, rubbing an injured part, or biting thelips in control of painful sensations, all of whichhave a definite and modifying effect on painthreshold.One would expect to find evidence of chronic

neuritis in the peri-anal region so richly suppliedwith sensory nerves. Histological examinationsconducted by Montgomery,4 and others havefailed to show evidence of such changes, althoughthese nerves are constantly exposed to stimulifrom congestion and oedema in addition to hyper-trophic skin changes and secondary infection inlater cases.

Lockhart-Mummery,5 however, is of opinionthat in any old-standing case definite disease ofthe nerve-endings is present owing to the effectsof constant scratching.The prevailing causes of pruritus ani may thus

be classified:

i. Excessive anal moisture.(a) Sweating and lack of cleanliness, especially

amongst those engaged in arduous work orheated atmosphere-miners, stokers, andthe like. Also, those involved in prolongedand uncomfortable sitting positions, suchas lorry and bus drivers.

(b) Discharge from infected or congested skintags, fissure, ulcer, condylomata, hyper-trophied anal papillae and inflammation ofthe sinuses of Morgagni (Cryptitis). Also,fistula-in-ano. Discharge may be due toa leaking ano-rectal abscess or to proctitiswhether simple, specific, or of the venerealtype commonly recognised as lympho-granuloma inguinale.

Anal epithelioma and rectal carcinoma are,of course, associated with chronic foetiddischarge.

(c) Mucoid leak from the rectal mucosa may-arise froni congested internal piles, especiallywith prolapse, and rectal polypi. Passivecongestion of the rectum associated withsphincter spasm in cases of chronic constipa-tion of the rectal type, may give rise tomucoid leak. This condition of spasmproduces in time a deposit of fibrous tissueknown by Miles as the "Pecten band." Itis a common abnormality in cases of pruritusani, and is termed pectenosis (Abel).6Weakness or paresis of the external

sphincter, together with prolapsus recti,is a frequent cause of mucous discharge.Mucous colitis may be another cause, sinceit invariably extends to and affects themucosa of the rectum.Drug idiosyncracy, strong aperients, pheno-

phthalein mixtures may excite excessivemucous secretion, whilst the intake of largeor prolonged amounts of liquid paraffin mayproduce a constant seepage or leak of thisaperient through the anal canal.

(d) In women, moisture may be derived frompruritus vulvae, often found associated withthe anal condition. In these cases, thepresence of vaginal discharge-particularlythat due to the Trichomonas Vaginalis-may be the focus, Cervical erosion ormalignant disease should likewise be men-tioned. Chronic cystitis with contaminationfrom septic urine is a frequent cause ofvulval and anal irritation.

Idiopathic pruritus in the female of thevulvo-anal type may occur in women suffer-ing from hypochromic anaemia.

Achlorhydria may or may not be present.

There is, also, an idiopathic variety found inpost-menopausal patients in whom atrophicchanges of the vulva and adjacent soft tissues,due to endocrine deficiency, are present. A some-what similar condition occurs frequently in old age.

2. Parasites.(a) Thread-worms, as a cause of pruritus ani,

are often found in children and youngadults. Oxyuris vermicularis may gain en-trance by .eating uncooked vegetables, salads,or through contact with an infected personby hands, towels, etc. These worms arevery small, about i in. in length, like littlewhite threads, and very motile. They areelusive and may need several examinationsfor detection. They are most likely presentin the anal canal or lower rectum towardsthe evening, when they tend to descend fromthe higher part of the rectum, causing

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May, I945 PRURITUS ANI 153

PHYSIOLOGICAL MECHANISM OF PRURITUS ANI

CAUSES

Ectodermal Endodermal Paradermal

I 2 3 4

Causes:- Primary skin in- Venous congestion, Reflex sensoryExcessive anal fections - back pressure on stimuli-segmentalmoisture: a. Streptococcal. External distribution.Sweating, lack of b. Mycotic. Haemorrhoidal Enlarged pelviccleanliness. . Plexus from Int. organs: Prostate,Discharge from Parasites- Piles, Proctitis. Uterus, etc.abscess, sinus, or a. Pediculosis. Constipation of rectal Cervical erosion.fistula. b. Scabies. type:- Intestinal parasitesExternal tags. Condylomata. Stasis, tissue fluid and polypi. (LatterMucoid leak: Epidermal changes accumulation. may create leak ofProlapsed piles, as in i, more in- Cell changes as in I. mucus, as I.)Prolapsus ani, flammatory reaction.New growth. Drugs.

IConstitutional pre-disposing factors: IDiabetes,Achlorhydria. OEDEMA Autonomic con-Dietetic errors. intercellular spaces and lymph - tinuation reflex:Paraffin seepage. channels. Swelling of prickle Afferent nerveChronic diarrhoea. - cells. Tension increased: stimu- impulse-lateral horn-Allergy. lation of intracellular nerve cels.

Efferent vaso-fibrils and special end organs dilatation:-in corium by way of medullated dlmetabolites, rise of

fibres to: tension.

Psychic factor,Lowered painthreshold:- I,Amplification.

Cutaneous branches of InferiorHaemorrhoidal and PerinealSecondary branch of 4th Sacral nerves.

infection, Other cutaneous nerves become

scratching, involved as condition spreads.Posterior grey cornua,Spino-thalamic tract,Thalamus, Certical fibres,Grey cerebral cortex:

PRURITUS

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154 POST-GRADUATE MEDICAL JOURNAL May, I945irritation from their movements. A lowsaline washout at such a time, together withexamination on a dark plate, will revealtheir presence.

It may be stated that thread-worm infec-tion, as a cause of pruritus ani, is far morecommon than is usually recognised-especi-ally in present times.

It should always be given careful investi-gation.

(b) The nematode, Enterobius vermicularis, isa not uncommon cause of pruritus. Itsnormal habitat is the appendix and caecum.The female worm descends to the rectum todeposit its ova. The movements of theseworms are the cause of the irritation andscratching. The ova become implanted onthe fingers, and the patient constantlyreinfects himself.A saline wash-out, with microscopic

examination of the residual deposit, willusually determine the diagnosis.

(c) Scabies and pediculosis are sometimes foundas causes of anal irritation. In the former,similar lesions of the acarus may be detectedon the wrists, between the fingers, andelsewhere.

3. Mycotic diseases.Fungi and pathogenic yeast moulds may affect

the perianal skin and give rise to a chronic formof pruiitus ani. They are rare infections. Suchlesions show desquamation, vesiculation, and acircumscribed well-defined border. There are oftendeep or superficial fissures in the skin so affected.A certain amount of intertrigo and lichenificationmay be present. Inspection of the clefts betweenthe toes, in particular between the 4th and 5th,often reveals desquamatory changes due to mycoticinfection. Tinea cruris, also, proves the diagnosis.A chronic streptoccal infection of the perianalskin may be difficult to distinguish from such anappearance, and it may be the primary cause ofthe irritation.

It is possibly due to the constant rubbing ofinfected faeces into the skin after defaecation.

In both there may be a well-defined border, butin streptococcal infection the edges are usuallybright red and smooth, whereas, in a mycoticcondition, they are dull pink and papular. Amongthe latter, a secondary infection may be super-added and mask the typical picture.

Microscopic and cultural examinations mayreveal the epidermophyton or tricophyton fungus.Culture is often very slow and difficult to attain.

In yeast infections, the Monilia Albicans is theeasier to recognise, as it gives an earlier and richeigrowth on Sabouraud's maltose agar.

4. Chronic idiopathic pruritus.Such cases, unfortunately, comprise a group

which has lasted for months or years, where nolocal focus has been found and for whom all kindsof treatment have been given with little or nopermanent relief.

Weariness, depression, and a chronic anxietystate gradually supervene, and mental changesensue in the worst cases. It is probable that, inmost of these, a trivial undetected local cause hasbeen present.

It may have since disappeared, or, if discovered,was inadequately treated.

Nevertheless, in a sensitive, temperamentalsubject with lowered threshold to pain and irrita-tion, the urge for scratching remains dominantand, apart from intervals of latency, becomesprogressive and uncontrollable.The initial psychological impulse is sufficient to

provoke a local vaso-dilatation and.oedema withstimulation of sensory nerve-endings in the pricklecell layer.

Reflex autonomic stimuli through the segmentalarc suffice to maintain this process of exudationand altered tissue tension.

PrognosisMost cases are amenable to treatment where

the local focus can be found.A certain number are extremely resistant and

show a tendency to relapse.This is sometimes due to non-co-operation on

the part of the patient and to the irksome natureof the treatment.

Complete confidence and willingness in carryingout the full ritual of treatment are essential forsuccess.

In early cases with active evidence of pruritus,a better prognosis can usually be given than inthose where no skin lesions are visible.

Gabriel, estimates that go per cent, providingthe cause is rightly diagnosed, are readily amen-able to treatment.Lockhart-Mummery8 considers that cases of

more than two years' standing are very difficultto cure, and the removal of the local lesion, evenif present, seldom stops the itching.The chronic idiopathic variety are, of course,

the most resistant.Some are relieved or, at least, improved by

psychological treatment.

EXAMINATION

A careful and complete investigation is neces-sary.The history, with any physical bearing or

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May, I945 PRURITUS ANI 155

psychological background, should be fully workedout.Worry, marital troubles, sexual deviations

should be noted for any possible influence onthe case.Abnormal mental make-up, hysterical mani-

festations such as patchy anaesthesia, exaggeratedknee-jerks, etc., are often present in the persistentand obstinate type of pruritus. Underlying consti-tutional disease may require investigation. Diet-etic errors, excess of laxatives such as liquidparaffin and phenolphthalein compounds, or drugaddiction, should be ascertained.

Urine examination for the presence of sugar,albumin, and acid or alkaline reaction must becarried out as a routine on all cases. Bacterio-logical examination will be required in cases ofcystitis associated with pruritus vulvae. 6

In blood investigations, the Wassermann reac-tion will be necessary for suspected syphiliticlesions, and t-e Frei antigen test for the diagnosisof lymphogranuloma inguinale-an obscurevenereal disorder more often seen abroad, but anot infrequent cause of pruritus in this country.Its main feature is chronic inflammation of themucosa and periproctitis leading ultimately tostenosis and rectal stricture.A differential blood count and haemoglobin

estimation will be required for anaemia. Thehypochromic variety is often found in womenwith pruritus vulvae.

Achlorhydria may be present in association withthis type of anaemia, and should be investigatedby fractional test-meal. In women, gynaecologicalexamination will be required for the presence ofvaginal or uterine disorders. In men, the prostateand seminal vesicles may need investigation.

In either sex an old gonoccocal infection shouldnot be overlooked. Direct pus smears and comple-ment fixation test should be carried out.

Pathological examination of muco-pus or faecesmay be required; the detection of parasitic ovahas already been mentioned. Finally, a biopsymay be necessary of any suspected neoplasmfound during the course of investigation.To carry out the local examination, a suitable

proctoscope of the Gabriel or Milligan patternand a good light-such as the Anglepoise areessential.The position of the patient is the next con-.

sideration.The left lateral position, with a suitable sand-

bag under the lower buttock, is convenient andcomfortable.

In the male, the knee-elbow position can beutilised with advantage. A more complete exam-ination can be made with the finger, and, uponintroduction of the proctoscope, the rectum

becoming distended with air and gaping owing tonegative pressure from gravity effects on theabdominal contents, a more extensive view is thusobtained.

Unless adequate local examination is carriedout, an unexplained and persistent case of pruritus.may be relegated to the list of idiopathics, whereasthe discovery of a chronic catarrhal proctitis oran infected crypt might easily explain the causeof the irritation.

In the case of suspected colitis or new growth inthe upper rectum or lower colon, sigmoidoscopicexamination must be carried out. It may bementioned that mucous colitis always affects themucosa of the rectum. If this appears healthy,there is no colitis, and the presence of blood andmucus must come from some other cause, usuallya neoplasm.

TREATMENT

(i) Hygiene.-In all cases careful attention tocleanliness is most important. This alone willcure a large proportion. The anal region shouldbe thoroughly washed with lukewarn water,using a white curd soap, night and morning andafter defaecation. Careful drying with a softtowel should be followed by the prescribed localapplication. Cotton wool should be used afterthe act of defaecation instead of paper. Localbody ventilation is also important. Aertex cellular,cotton mesh, silk or artificial silk underclothing,loosely fitting, should be substituted for heavywoollens or much darned and coarse materials.The same applies to night apparel.Hairy subjects are much benefited by perineal

shaving whilst undergoing treatment.(2) Diet.-Over-indulgence in food and drink

must be corrected. Highly seasoned foods, condi-ments, curries, etc., should be avoided. Meatshould be restricted. Shell-fish, strawberries,strong tea and coffee, as occasional causes ofpruritus, are likewise forbidden. Moderation inalcohol and tobacco should be exercised, but, ifpossible, it is wiser to stop all alcoholic drinks. Incolitis, where irritating mucus may lead topruritus, the dietary should be overhauled and anyidiosyncrasy corrected.- In most cases a simplelight diet, including milk, butter, fresh fruit andvegetables, with avoidance of acid-forming foods,should be prescribed.

(3) Medicinal.-The daily action of the bowelsneeds due attention. If laxatives are required,senna is probably the best drug. It has a moreselective effect on the lower part of the largeintestine. Milk of magnesia is also recommended.Any vegetable aperient, however, may be tried.Saline aperients and phenolphthalein should not begiven owing to their irritative effects on the

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156 POST-GRADUATE MEDICAL JOURNAL May, I945

mucosa. Liquid paraffin may be used in modera-tion and for a given period, but its tendency toaccumulation and seepage, causing anal leak,should not be forgotten.Owing to the nocturnal nature of this complaint

with consequent loss of sleep, luminal can begiven in J gr. doses night and morning; or, if sodesired, in i gr. doses at night only.Luminal is regarded by many as almost specific

in its effect on pruritus and lends support to thelarge neurotic factor in this condition.

Adalin, bromidia, and the like, may be triedalternatively in milder cases.Morphia and opiates should never be given

owing to the risk of drug addiction.Ultra-violet light is often beneficial both as a

local application as well as general body radiation.In cases of avitaminosis, a course of vitamin A

as cod-liver oil or haliverol should be given.Where achlorhydria is present, hydrochlor.. acid

dil., i to i drachm in water thrice daily shouldalso be administered. Cases of hypochromicanaemia should be treated with ferrous sulphate incombination with acid hydrochlor. dil.

In vitamin C deficiency, black-currant jelly orsyrup, or ascorbic acid tablets, 50 mgm., may betaken twice or thrice daily.Endocrine dysfunction in post-menopausal

patients should be treated with stilboestrol orsther oestrogenic preparations.

(4) Local treatment.a. Surgical.-The extensive group of ano-rectal

disorders that have already been enumerated willrequire surgical treatment. Such direct causes ofpruritis as piles, fissure, prolapse, etc., whenadequately dealt with, will be followed by perman-ent cure in most cases.The injection of internal piles, excision of skin

tags, cauterisation of hypertrophied papillae, maybe cited as such instances of minor surgery.Neoplasms and the more extensive conditions

will require appropriate investigation and treat-ment.

b. Local applications.-Magnesia lotion appliedmorning and evening is very efficacious in earlycases.The following formula is used at St. Mark's

Hospital:

]FgPhenol .. .. .. I drachmZinc oxide .. .. .. 2 drachmsPulv. calamine prep. .. I drachmGlycerine .. .. .. 2 drachmsSp. Recti 2.. .. .. drachmsAq. rosae .. .. .. i ounceMilk of magnesia ad. .. 4 ounces

Later, or as an alternative, a dusting powdersuch as Calamine i part, Starch powder 2 parts,may be used. This can conveniently be appliedin the morning, and the lotion in the evenings.A pledglet of wool containing this lotion may beinterplaced in the anal cleft at night time.

Ointments are generally contra-indicated owingto their greasy nature and impermeability, some-times causing irritation. They are occasionallyuseful in dry dermatitis and in chronic or suspectedmycotic conditions.

In such cases Aird Scott recommends the use ofWthitfield's ointment:

B Benzoic acid .. .. 4 gins.Salicylic acid 1.. .. gMns.White petroleum jelly .. I20 grns.Coconut oil.. .. .. ad. I oz.

This should be sparingly employed, and may notbe tolerated for long. It may b% replaced byIchthiol paste with the addition of Oil of Cade,20 mins. to the ounce.The formula of Ichthiol paste is:

1R Ichthiol .. .. .. 40 mins.Zinc oxide .. .. .. I20 gMns.Lanoline .. .. .. I20 gins.Petroleum jelly .. .. ad. I oz.

In acute dermatitis, Miles has found the followingvery useful:

I Pulv. zinc ox. .. .. 2 drms.Lin. camph. .. .. 3 drms.Anaesthesin. . .. .. 2 drms.Lanoline .. .. .. I drm.

Alternatively, Lockhart-Mummery recommendsthis formula:-

Bismuth subnitratis .. 2 clrms.Cocaine .. .. .. 10 gins.Hydrarg. subchloridi .. I5 grns.Vaseline .. .. .. I OZ.

In chronic cases with fissures and excoriations,Gabriel finds that healing is often obtained bypainting the skin with Silver nitrate, 30 grains tothe ounce, Bonney's violet-green paint may alsobe tried, or Blanchard's I-B paint.The formula of the latter is:

]F Tinct. Iodi. CCP triturate formula:Tinct. Benzoin Co 13 CamphorCCP triturate part. Chloral hydrate

aeq. Phenol part. aeq.

Any of the above paints may be applied onceor twice weekly.

I-B paint is much used at St. Mark's Hospitalon selected cases.

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May, I945 PRURITUS ANI 157

Patients should be advised to avoid scratchingthe part with the finger nails. Pinching theirritable part outside the clothes does less harmand affords some relief.

Treatment must be continued for severalmonths in spite of apparent cure, otherwise thepruritus may return.When an attack of irritation is threatened, the

application of 2 per cent carbolic lotion with spiritand rose-water will often prevent its development.A pledget of cotton wool soaked in this lotionshould be inserted in the anal cleft. The lotionshould be kept handy at night-time.

Gynaecological conditions will, of course, requireappropriate treatment apart from that directed tothe relief of pruritus ani.

(5) Parasitic.a. Oxyuris vermicularis should be treated by

strong salinemInjections- 2 tablespoonfuls to i pintof warm water. This should be injected into therectum at night-time by ordinary enema syringe.A dose of castor oil should have been given previ-ously to clear the bowel.

b. Enterobius vermicularis is treated by givingSantonin 2 grains and Calomel i grain (Adultdose) for three nights in succession. Thymol mayalternatively be used: A purge is first given followednext morning by Thymol i drachm, repeated intwo hours by another i drachm. A saline purgeis given two hours later.A strong saline injection of the strength already

mentioned-four ounces-should be carred outat the time of irritation, which corresponds to theprobable presence of the female worms in therectum.Adequate precautions must be taken against

re-infestation.c. The treatment of scabies is carried out by

sulphur applications. Pediculosis is treated byshaving and the usual mercurial ointment.

(6) Local injection treatment.Various sclerosing drugs injected deep into the

perianal tissues have been advocated. Dilutehydrochloric acid, alcohol, and quinine-urea haveproduced sclerosis with successful result in free-dom from pruritus. This has been obtainedchiefly by those few who have worked withthese drugs. There is considerable risk of slough-ing and other complications, and their general useis not recommended. The oil-soluble anaestheticpreparations, on the other hand, are safe andvaluable in the treatment of obstinate cases wherelocal surgical and medical attention have failedto dispose of the irritation.

Injection by these drugs should, therefore, be

reserved until local means have been tried over avarying period.

It is then preferable to have the patient in bedfor a few days, either in hospital or nursing home,while the injection treatment is being carried out,and local applications can be more carefully andregularly given.Yeomans first described the use of an anaesthetic

solution in almond oil in 1927, and produced thesolution known as Benacol.

Since I929 a solution called A.B.A. was pro-duced by Gabriel and prepared by Allen & Hanbury.This has been most popular and satisfactory, andused by many in this country.

It consists of 3 per cent solution of anaesthesinwith benzyl alcohol 4 per cent and ether io percent in sterilised olive oil.

Recently another solution, devised by Morgan,and known as Proctocaine, is most successful inits results. Like A.B.A., it is frequently used inthe treatment of anal fissure.

It contains Butesin 6 per cent, Benzyl alcohol5 per cent, Procaine base I *5 per cent in sterilisedalmond oil.As regards technique, scrupulous cleanliness and

the usual aseptic ritual must be observed.The anal skin must be cleansed with soap and

water after shaving, and tincture of iodine appliedto the whole area. A' sedative should be givenbeforehand.The patient should be placed on the left side, and

the lower buttock suitably elevated with a sandbag.Usually 4 punctures are made, two on either

side of the anus postero-laterally, and about 8 toI2 ccs. are injected. A deep radiating injectionof 2 to 3 ccs. is made in each, seeping should beavoided, and gentle massage with the finger inthe rectum will prevent this. Care, of course,must be taken to avoid puncture of the analcanal. A second injection of a smaller amountin 2 punctures of 2 5 ccs. each may be given in7 to IO days' time if required.By this means the sensory nerves in the ischio-

rectal fossa, inferior haemorrhoidal and 4th sacral(perineal branch) are anaesthetised.

It is usually advisable to continue sedativetreatment, such as bromidia, during the followingfew days.A sensation of numbness in the perianal region

is produced and lasts a few weeks, but the irritationdisappears at once. Local treatment can beapplied with more effective results.

It may be said that with increasing experiencein examination, and correct local treatment,the use of these injections should only occasionallybe required in treating pruritus.

Special surgical operative treatment, such asBall's operation by undercutting the perianal

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158 POST-GRADUATE MEDICAL JOURNAL May, I945skin, or division of peripheral nerves, as in Stoeffel'soperation, are not popular with most surgeons.The results are unsatisfactory. The techniqueof Ball's operation is difficult to carry out, althoughappearing easy on paper, and the rationale ofdividing definite nerve lesions being sound.Lockhart-Mummery, however, states he has

performed this operation since 1905 with excellentresults, and advises it in old standing cases.Deep X-ray therapy is not recommended owing

to various risks involved in skin changes andfrequency of relapse.

REFERENCESx. MACLEOD, J. M., and MUENDE, I., Pathology of Skin.2. RIDDOCH, JOHN W., Lancd, 1937,, 919.3. LIVINGSTON, W. K., Pain Mechanisms.4. MONTGOMERY, H., Mayo Clinic Monographs, 1931.5. LOCKHART-MUMMERY, J. P., "Treatment of Pruritus Ani,"

Post-Graduate Med. JI., October 1934, pp. 429-434.6. ABEL, LAWRENCE, Brit. Med. Ji., 1939, p. 627.7. GABRIEL, W. B., The principles and practice of Rectal Surgery,

pp. 189-204, 1937.Brit. Med. JI., 1929, pp. 1070-I071.

8. LOCKHART-MUMMERY, J. P., Diseases of the Rectum and Colon,I934.

SURGICAL CLOSURE OF THEPATENT DUCTUS ARTERIOSUS

By 0. S. TUBBS, F.R.C.S.(Surgeon E.M.S. Chest Unit.)

Interest in persistent patency of the ductusarteriosus has increased greatly since surgicalligation of this vessel was first successfully per-formed by Gross in August I938 (Gross andHubbard, I939). Munro (1907) suggested such anoperation in infants, but it was not till Strieder(Grabiel, Strieder and Boyer, I938) attempted itsperformance in an adult that the practical possi-bilities of this procedure received serious considera-tion. Further interest has been stimulated by thedemonstration that some cases complicated bysubacute bacterial endarteritis can be cured oftheir infection by ligation (Touroff and Vessell,I940, and Bourne, Keele and Tubbs, I94I).Up to the present time about 200 cases

of patent ductus arteriosus have been treatedsurgically, and it is therefore time for a carefulreview of the results obtained and the indicationsfor and technique of the operation. Nine of myown I2 cases have been ligated in the presenceof endarteritis, and the importance and frequencyof this complication will receive particular attention.

Pathological Effects of Persistent Patencyof the Ductus ArteriosusDuring foetal life the ductus arteriosus is a

relatively large vessel connecting the bifurcation of

the pulmonary artery to the aorta, and has theim-portant function of allowing a large part of theright ventricular output to enter the aorta withoutpassing through the pulmonary circulation (Fig. I).Normally the vessel becomes functionally closedwithin a few minutes of birth (Barclay et alia,I942), almost certainly as a result of contraction of

FOETAL

FIG. I.-Diagrammatic representation of the foetal circu-lation (arrow in the ductus showing the direction ofblood flow).

its extraordinarily well-developed muscle coat(Kennedy and Clark, I94I). Anatomical oblitera-tion of the lumen follows within the first few monthsof post-natal life. The cause of patency persistinginto childhood and adult life is entirely unknown(it is interesting to note that it remains patenttwice as frequently in females as in males), butwhen it does so the flow of blood is reversed, i.e.oxygenated blcod flows from the aorta into thevenous stream in the pulmonary artery (Fig. 2)

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