MARCH 2, 191241 . PRURITUS VULVAE. TM:I JoDUA 469

s irritation increases in direction the amount of friction grows in proportion, until finally what has been aptly 3Trturt termed "hysteria of the skin" is developed, and the poor ON woman scratches herself until she is quite exhausted and the paroxysm is over. It is in these severe cases that so PRURITUS VULVAE: much harm is done to the delicate mucous membrane, for thle scratching leads to changes in the tissues which keep ITS ETIOLOGY AND TREATMENT. up abnormal irritation. DELIVERED AT THE MEDICAL GRADUATES' COLLEGE AND ETIOLOGY. POLYCLINic, DECEMBER 13TH, 1911, The more experience one the more one is impressed Y gains, -$ Y by the fact that true essential pruritus vulvae must be R. A.. GIBBONS, M.D., F.R.C.S.E., very rare indeed. In all the cases I have had to deal with I could say was a pure PHYSICIAN TO THE GROSvENORIO HOSPITAL FOR WOMEN, LONDON. I have rarely met with one which neurosis. By this I mean that the causation of the suffer- the our ing is located in the spinal centres, and that changes I HAVE chosen the subject of pruritus vulvae for which gives risc to lecture this afternoon because I think that a careful study there leadtheto pruritus, eventually greatest no local signs ofchlange in the mucous membrane. Accord- of the etiology and treatment will be of the ing to my own experience-and I have had a fairnumllber possible value to any who are attending a post-gradutat of severe however, by nio means course with a view of benefitingthemselves by practical thlese cases,which are, work hereafter. common-Ihave found that in nearly every case a local than is cause can be discovered, even though it may take a PrPritus of the vulva is far more common considerable amount of time to ascertain. generally supposed, because in the milder forms, on account of natural advice not sought from lThe following case quite illustrates what I mean, andl principally modesty, is shows how careful one to be before stating the and whien the y has increased, ought family physician, maladl that no external cause can be discovered: the case may be seen only for the first time by a gynaeco- dogmatically logist. It is an affection whichb, in its severe form, short Alady aged 58 consulted me in December, 1903, on account of jeopardizing life, may be considered one of the most ofdiscomfort caused by a caruncle of the urethra. Shelhadnlo terrible with which woman be afflicted, for it uterine history. Her period had ceased seven year; s any may specialpreviously. She had had two children, the last born over gives no peace-no lengthened freedom from irritation or twenty- years ago, and her recoveries from her confinements itching. When a paroxysm comes on or passes off there is were satisfactory. She - had what she termed" a nervous always the mental strain and anxiety concerning the next illiness " some years before, and eighteeii months beforeher which may occur, and in cases which have lasted some visit to me shehad acute cystitis, whenshewas laid up for present. In three weeks. Therewasnothing to be discovered on examinationt time the apparent hopelessness of cure is ever of the abdomen orpelvis, but there wasasmall fleshyearuncle on some, unquestionably, death is looked forward to as a happy the posterior wall of the urethra. I remnoved-the carunclanle, da.lI release, and occurs by suicide. It may truly be said that local (liscomfortceased. Aboutthree years latershe again com- amongst those who have suffered severely, andhlave been plained of local pain and'discomfort on' micturition, an(d o cured will be found the most examinationI found a recurrence of the caruncle. I'againi by judicious treatment, removedthe caruncle, which brought immediate relief. This grateful patients. It is a disease whlichl, once established, lasted several months, when she began to complain of frequent is exceedingly difficult to cure thoroughlly and com- attacks of pruritus vulvae, coming on at allhours, but worst pletely, whilst the milder forms readily yield to proper (luring the night, breaking hex rest. There was no trace of management. caruniicle left, and the urethral orifice appeared perfectly SYMPTOMS. healthy.l'here wasnothing about the clitoris ornymphlace calling for attention. The attacks were becoming more fre- It will be most simple to divide the subject into quenit, in'spite of all the treatment adopted, until opium in the (1) synmptomatic and (2) essential pruritus vulvae. The form of pill was the only drug which brought relief. When latter must be considered a neurosis. micturitioni took place' itfrequentlv wasfollowed by a paroxysm. The word"pruritus" merely means itching, and of She could not quite locate the origin of the attacks, but the else. itching seemed to start from a point between the clitoris an(d course must be therefore symptomatic of something the oritice of the urethra. Here was a case which seemed one of It is a subjectivesymptom, and may be present in a varying essential pruritus. As she had had twocaruncles removed,and(1 degree. Sometimes it feels as if there AN-ere sliglht smarting an attack often followed micturition, I thought it would pos- accompanying the itching, and sometimes a tingling, burn- sib)ly throw some light upon the case if the bladder and urethra or the variety termed were carefully examined. Under ether I dilated the urethra ing, pricking, sensation. Perlhaps and explored the bladder, and then discovered oIn the posterior "formication," where the sensation is that of thousands of wall of the urethra a small, deep, oval ulcer, 1j mm.long1) insects crawling over the skin, is the most terrible to bear. I40 mm. broad. This I touched with the Paquelin cautery and The objective signs are usually those of someinflammatory she recovered rapidly, having no more attacks for a consider- disturbance, as a rule confined at the commencement to able time until aniother urethral ulcer developed. This might tIme neighbourhood of the clitoris and nymphae, and easily have passed as a case of essential pruritus had the gradually involve the whole region of the vulva. urethra not been dilated. In an ordinary slight case of pruritus vulvae there In discussing the etiology of this affliction, it may be nmay be little or nothing to observe; but even in the remembered in the first place that most of the cases met slight cases there is usually some form of irritation about with of true pruritus vulvae are in women who are passing tlle mucous surfaces of the labia majora, or on the througll or who lhave passed through the climacterie nymphae or vestibule, to be detected if carefully looked period, that is to say, when the ovarian functions are for. The amount of itching may be quite trifling, and dimninishing or have ceased. Whether there is any con- only occurring occasionally during theday, and especially nexion between the pruritus and the gradually failing at night, when the patient is in bed. In the more severe glands, or wlhetlher it is merely a coincidence, we cannot cases of symptomatic pruritus tlie paroxysms of itching positively say in tlle present state of our knowledge, but it are more pronounced but longer, and are accompanied by is a fact. Every case must be thoroughly investigated, well-marked changes locally. The parts feel lhot and anid inmost it will not be difficult to ascertain the cause if burning, and, if much scratclhing has taken place they seen reasonably early. According to Bronson,' mnay be swollen, raw, and bleeding. After a paroxysm is Of the conditions that act as predisposing causes of pruritus, over the surfaces are exquisitely tender in the early stag'es, whether it occurs as an essential disease or is predomiinate(d by and the patient cannot bear the least touclh witlhout pailn. some other disease of which it is a symptom, by far the inost The attack may begin by a slight point of itching in the imnportant is hyperaesthesia. This may be either congenital or nieighbourhood of the clitoris or in the vestibule, and very acquired, either local or general. It may b3 acquired throuhl But diseases which affect the economy at large, or that are localize(d slight friction may for the moment give relief. the in the skin. The general diseases producing it may be i(lio- itching recurs and the scratclhing is repeated, the area of pathic neurosis, such as hysteria and hypochondriasis and(l irritation growing larger and requiring more friction to other affections of the nerve centres, or general nutritive give relief, until finally the field of- irritation, whiich diseases affectingi the nervous system secondarily, suchi as, started about the size of a pea, grows sufficiently large arthritis or diabetes mellitus. In all the cases the prinaif-ry the effect of th-e general disease is simply to heighten the suscepti- to include the whole of the vulva, and sometimes b)ility of the pe.ripleral nerves, causing exaggerated sensatiolis pabes, leading to gradual wearing away of the hair and from the slightest contact. The exciting causes consist of clhanges in the skin of the lower abdomen. As the rritartion'sthat Laav he either indirect and conveyed to the slin [2670] or direct, in whicllTIRURITUS VULVAE. excit3tionthe40isLproduGed-byinteriormzDicALjoumAof thelocalbody, case the [MARCH 2, 19I2. fromestrawneous irritants, - sources or. whether -.- L from sourcas that are intracutaneous.arisi-llg from from the interior of the body, or direct, in which case the According to Moraezowski, glycosuria is accomnpanied by excitation is produced-by local irritants, whethier ar.ising from an elimination of extraneaus sources or from sources that are intracutaneous. exaggerated calcium. It would be simple to deal with all cases of external In some the pruritus may have started from a slight irritation at once. Pediculi pubis and ascarides may be abrasion due to mechanical injury or excessive coitus, or the cause of severe pruritus. I have seen a case of great the delicate epithelium may have been affected by an severity caused by the former. By the time I saw tlle irritating secretion. In the latter case it will depend on patient she was in a pitiable condition, for she had been the nature of the micro-organisms attacking the mucous travelling for three days across the Continent without any membrane.2 Some think that the scratching leads to means of obtaining relief from any kind of treatment. On superficial abrasion and laterulceration, wlhich yields an discovering the cause, she recovered very rapidly under exudate, and that this is carried to the adjacent skin by ordinary treatment for pediculi pubis. Ascarides are scratching, which setsup irritation similar to the original. rarely a cause of pruritus. Th-ley may be difficult to A common cause of severe pruritus is sugar in the urine discover, but when once found, the treatimient is simiiple in cases of diabetes. It is a good rule to examine the and effective. urine in every case of irritation of the vulva, in order to see Amongst the micro-organisms whichl are comnmon as a if there be any sugar present, or if the urine be loaded with cause of pruritus is-perhaps the Qidilm albicans ofthlrtshl uirates or uric acid, or oxalate of lime crystals. In either and the gonococcus. The latter is certainly the cause in case the urine has the power of irritating the mucous many cases. It leads to an inflammation of the mucous membrane and bringing on attacks of pruritus. The mere membrane of the vagina, which pours out a more or less fact that pruritus vulvae is present should make one think continuous discharge, which, irritatingthemucous mem- of diabetes, for the two are so commonly associated. brane of the vulva, induces the pruritus. Ilhave seen Indeed, it is often the gynaecologist who discovers that several cases which could be distinctly traced to the diabetes is present from the fact that he is consulted on coccus, in whlich the pruritus was developed early ingono-the account of pruritus, and is able to advise the patient to attack of vaginitis, and persisted. In some of these cases place herself in the hands of the family physician. Some the acute symptoms of inflammation 'may gradually sub- are of the opinion that diabetes is the principal cause of side, and leave the paroxysm of pruritus unaffected. pruritus. It induces irritation by allowing the mucous Although the vaginitis may be due in some cases to the membrane to be constantly covered with urine loaded gonococcus, there may be an acute attack of inflammation with sugar. Probably, also, the linen is apt to be so of the vagina which cannot be traced to the gonococcus, frequently moistened that, unless constantly changed, de- and which leads to pruritus. Passing upwards from the composition of the urine may take place and micro- vagina, the cause of attacks of pruritus vulvae may be due organisms develop. Diabetic urine, decomposing under to inflammation in the neck of the uterus, or of the endo- the influence of yeast fnngus, is very irritating to the skin. metrium. I say "may be due," forlhaveI nothing which Up to the present we know of no micro-organisms which I could call evidence to lead me to state that such inflamii- are particularly associated with diabetes, and which may mation of the mucous membrane of the cervix or be said to cause pruritus. When certain inflammatory certainly caused pruritus. Nevertheless such causesuterus3have conditions are set up in the mucous membrane, as in been mentioned by authors of repute, and I merely call gonorrhoea or thrush,thle changes which occur in the attention to them here. mucous membrane are due to micro-organisms. It is In addition to want of cleanliness, which ought to be probable e that the continued saturation thlof mucous borne in mind as a possible cause of pruritus, anyconldition membrane by highly-charged diabetic urine starts such which produces discharge may lead to it by its irritating irritation that micro-organisms come to the front. Some properties on the vaginal mucous membrane. It is in this are of opinion that this condition of mucous membrane, manner that cancer probably acts. By the extremely leading to pruritus, is due to a condition of the blood, for irritating effect of the secretion of the malignant uterus, otherwise sugar-loaded water would not of itself set body or cervix, an inflammatory condition is set up up pruLritus. The experiment of allowing a compress which leads to- frequent scratching. In like manner. just grape sugar saturated with a solution of to be placed over before, during, and aftero the rdinary period, a most severe the vulva and remain all night has proved that in a attack of pruritus may be set up in an otherwise perfectly healthy woman pruritus has not been established or any healthy woman. This is doubtless due to somec irritating h arm done. The irritation set up in the delicate mtucous properties of the secretion. Some women hiave periodical memubrane of the vulva by sugar-loaded water is analogous attacks of more or less severe pruritus at the time of thle to thatbrough t about by highly concentrated urine, or period, and are not bothiered withi it at other timiies. Some urine loaded withi urates or uric acid, or oxalate of cases of pregnancy accompanied by pruritu-s vulvae are lime crystals. The latter undoibtedly prick thle mucous most instructive, for they only occur at certain times anid membrane with their sharp points, and by this means at no others. In the latter cases extensive areas of the micro-organisms are allowed to penetrate thie epitheliuin, skin may be affected, and an attack commencing in the and set up the irritation which leads to pruritus. This region of one of the nymphae may lead to seems to be a reasonable explanation, and therefore one scratching over all the lower part of the abdoMen.intenisAt the need not look to thle blood itself circulating in and about very beginning of the attack of pruritus in pregnancy the the as a region of tbe vulva cause. It can only be con- irritation may be triflingthland e scratchinig may be sidered due to the changes in the blood, inasmuch as the confined to a small limited area in the vestibule, but if the urine is affected thereby,ad d consequently produces actual attack does not quickly pass off the wave of irritation irritation of the mucous membrane. Seeligman,3 in an increases to such an extent that finally the patient investigation of a large number of cases, found in all a scratchesthee whole of the lower part of the en. diplococcus, which resembles the gonococcus in appearance, I have seen large areas of the skin of the abdomenabdoecovered buit differs from it in the process of growth, and besides it with bleeding marks from scratching. takes the Gram stain. He considers that thlis accounts for An ordinary attack of eczema, which is quite common in the pruritus. Saengar4 is of the opinion that the pruritus the region of the vulva, may bring on pruritus. It does of diabetes haematogenous, is and analogous to the not always do so, for I hiave seen many cases of eczema pruritus of jaundice. But I think the explanation I have of the vulva withi no real pruritus. On the other mentioned seems reasonable. hand, very slight cases of ordinary eczem'a of the labia Veit," whose experiment with grape sugar I have quoted, may be the means of producing most severe attacks of thinks that the irritation is due to some, other constituent pruritus. I have seen most distressing cases of ordinary of the urine besides grape sugar, and points out that men eczema, which has rendered life almost intolerable in with diabetes suffer from pruritus of the scrotum, probably gouLty women, and I have observed that the eczema because the underclothing is continually moistened, lead- always started first and the pruritus followed.aasIn some ing to softening and irritation of the skin. Although of these cases of ordinary eczema. if one is fortunate is so in diabetes, prurituis common it is certain that all enough to cure the patient quickly by treatment, no cases are not accompanied by pruritus, although slight and pruritus develops. If, on the other hand, it is obstinate severe cases of vulvitis may be met with. The remarks in yielding to treatment, pruritus may come on. with reference to the urine in diabetes apply equally to There is one source of origin of pruritus which ought to the urine in nephritis, for it seems to bring about the be mentioned, and that is the presence of a pessary. Some pruritus by irritating the sensitive mucous membrane. women are very careless about themselves and are apt to MARCII 2, I9I2.] PRURITUS V'ULVAIE. Iva B MAnOR1912.]2, PRURITUS VTTLYAE. 1, JaZDZCALTEN TOUJUCAL 47T Bumuw~~~~~~~~~~~~~~ forget about wearing any support at all. I remember -well vulva, vagina, or cervix, uterus or adnexa. There was this one old woman who came to the hospital on account of peculiarity, that the intense itching seemed high up in the severe vulvae. The cause was the of vagina, and that the patient did not serxtch, for she found that pruritus presence a any pressure or scratching of the vulva difl not give the slightest pessary which she had worn for many years, and which relief. She knew that the intense itching -.as too high up to be she had forgotten entirely. On removina the pessary, reached, and she therefore bore the irritk'tion as long as she which was thickly coated, there was ulceration of the could before using some vaginal doucheb vaginal walls from pressure. After the removal of the Another case was that of a widow, aged 46, wr.om I saw in con- and treatment she lost the sultation with her own doctor. Her case wai'r' similar to the pessary proper pruritus. last, inasmuch as the irritation came in severe ptr-oxysms, high Another cause of pruritus vulvae is undoubtedly mas- up in the vagina. I examined her most thoioughby, and could turbation. The onset is doubtless due to the irritation detect notlhing wrong, either in the vagina, uteru&- or adnexa. caused by the removal of the superficial epithelium in This lady told me that she had the most maddenint, attacks of consequence of friction with insufficient lubrication. It itching in the niight. She could obtain no relief from soratching, leads to the of in and therefore there was no temptation to scratch, so 'hat the attacks pruritus the same manner as vulva was perfectly normal, and showed none of the uivral signs a minute crack or fissure of the mucous membrane. with whichiwe are familiar in the ordinary cases of pruritus. There is one local trouble which you will find men- tioned as a common cause of this affection, and that is In both these cases, although I could detect nothing, it small varicose veins. I have never been able to satisfy is open to anyone to say that possibly had I dilated the mlyself that varices produced pruritus, for in association uterus or uretlhra or cystoscoped the bladder, I might have with them I have always found some chronic discharge, found some cause for the severe attacks of itching. These which I have put down as the cause of the pruritus. cases -certainly appear as those which inight be classified I cannot recollect any case where I have seen small veins under the term " neurosis." There are certain neurotic alone bring on the attacks. patients who experience sexual excitation in the form of There is one source of origin of the affection which may itching, which often leads to masturbation, and in them no be easily overlooked, and which will show the importance apparent external cause can be discovered. Such cases of having a thoroughly good light for examination, for are found in asylums and amongst those suffering from apparently it is very slight. It consists of one or more nervous affections. In them the centre for the pudendal ulcerations, which in appearance may be healthy. These nerves may be affected so that irritation may be perceived are usually situated round the orifice of the' vagina beyond at various parts of the vulva, sometimes at different points the hymen, sometimes on the hymen itself, called by of the vestibule, and sometinmes in one or other labium. In Matthews Duncan6 lupuLs minimus. These little ulcera- any case, scratching produces temporary relief, and with it tions heal up with or without treatment, and break those changes in the tissues which themselves lead to out in other parts. They are usually associated with scratching, so that a vicious circle is established. The little hypertrophies, such as hypertrophies of bits of scratching eases the itching for a time, but the very relief the hymen or'of tlle orifice of the urethra. These spots whiCh is brought about is at the cost of minute changes in of ulcerations are exquisitely sensitive, and I have else- the tissues wlhich cause further scratching. where called attention to them as being a cause of dyspareunia, and also of vaginisimus. I consider them of PATHOLOGY. great importanice in the etiology of pruritus, especially as The most important point to determine witlh reference to they may easily escape detection, and my belief is that in this is whether it is to be looked on as a purely local certain cases of so-called essential pruritus they are really disease, or as a neurosis. Some8 regard it as a sensory the origin of the disease. In some cases I have discovered neurosis, and that it is a nerve disturbance "without a small ulcerated'surface at the posterior fourchette, much associated appreciable structural change, and the provoca- larger than the minute ulcers I have mentioned. The size tive irritation may be either of reflex origin or direct, and seems to depend on the' amount of time the ulcer has may have its seat in any part of the nervous system, from been in existence, for the edges are apt to be slowly centre to periphery. The tissues remain unaltered tlhrough- extended, but thegrowtlh in circumference is extremely out t.he entire course of the malady, except so far as slow. I feel sure that many cases of pruritus lhave these secondary conditions are in some instances brought about small ulcerations as tUeir starting point, leading to by persistent scratching and rubbing." exposure of 'the terminal filaments of the sensory nerves The sensory nerve supply of the vulva is contributed by distributed to' the vulva and vagina. If a careful search the inferior pudendal, the ilio-inguinal, and the genital be not made for them they will certainly be overlooked, branch of the genito-crural nerve, as well as by the two and the patient suffers from want of success in the varied perineal branches of the pudic, and the nerve of the treatment. In Surgery of the Rectum Sir F. Wallis7 dorsum of the clitoris. In any part of the course of these remarks that 'the chronicity and great frequency of cases nerves, from the origin onwards, it may be contended that of pruritus ani in the out-patient department of St. Mark's some pathological change takes place which starts the Hospital made hiim investigate for some possible cause, irritation at certain points. The local changes are those and that some years ago he made a point of examining with which, in the vast majority of cases which come every case of pruritus ani both digitally and by means of a before us, we have to deal. It will depend much on how speculum. In over S9O per cent. he found a small shallow long the pruritus has lasted what clhanges we find. In ulcer situated usually between the two sphincters, more those which have lasted a long time we shall see those often in the posterior half than in the anterior, and evidences of chronic change in the vulva and its neiglh- generally near the dorsal mid-line. In some cases there bourhood with which those who see these cases frequently were more than one ulcer, which was usually a shallow, are familiar. The skin has lost its freshness, and appears oval livid abrasion, differing markedly and mainly in duller in colour than natural. There may be a distinct colour from the normal mucous membrane. I consider hypertrophy of the nymphae and labia majora, which this extremely instructive, that in so large a percentage feel hard and leathery to the touch, or there may be the cause was discovered. merely slight oedematous infiltration. If the disease has lasted a considerable time, the appearance of the tissues Essential Pruritius. reminds one sometimes of those soaked in spirit as to We now have the other division of the etiology-namely, colour and consistence-all the elasticity has gone. There the essential pruritus. I cannot assert that there is no are invariably also signs of severe scratching in the such condition, but I maintaill that it is exceedingly rare. fissures, and blood-cavered marks all over the affected In very nearly all the cases with which I have had to do I region, and in some cases regular ulcerated patches. Veit9 lhave almost invariably been able to trace the cause of the says that "microscopically, in the thicker parts of the discase. There are, however, two well-marked exceptions skin which show these changes due to pruritus, there is an which have impressed themselves upon my mind. inflammatory parakeratosis, a picture of subepithelial Onie was that of a lady sent to mne from the country by her small-celled infiltration. Tlle formation of keratin is family plhysician, wlho told me that he had tried everv-thinig he arrested, and in this way desquamation of tIme horny could think of in the way of treatment without any good what- layers takes place irregularly. The process is distinct ever. The patifent, aged 42, had suffered from continuously from in that the as a severe attacks of pruritus, generally commencing soon after vaginitis, epidermis wlhole, and in its gettiDg into bed at night, and sometimes waking her up inl the external layers especially, undergoes an even thickening, middle of the.night. I examined her most carefully, but could in contradistinction to the thinning process that takes finid absolutely nothing which seemed abnormal, either in the place in vaginitis." In one case of pruritus vulvae 472 MIDCL os' PRURITU%,-S VULVAE. rMARCH 2, 1912. IK. Czerwenka10 found " hypertrophy of the papillary con- by Lawson Tait. Attention has been devoted to it by nective tissue, atrophy of the epithelium, multiplication Petit and Pichevin, as well as others1' in France. It must and distension of vessels, diminution of the glandular not be confounded with leucoplakia, from which it is cutaneous elements, as well as subepithelial round cells." distinct, but the two diseases may be met with together. These local changes are well described by Webster1" and According to Breisky, "Kraurosis vulvae is an atrophic by Saenger,12 and they are taken from the examination of retraction attackiiig the vaginal orifice, the labia minora portions of skin removed by operation in intractable cases the fraenum and prepuce of the clitoris, and the interior of pruritus. The clitoris is the most sensitive part of the surface of the labia majora. This retraction is accompanied vulva, and next to that is the preputium clitoridis, the by necrosis of the epidermis and by hypoplasia of the nymphae, and finally the labia majora. Two groups of conjunctive tissue, causing retraction and shrinking of the the genital bodies known as the genital corpuscles of genital organs." In these cases the patient usually comi- Krause-tactile corpuscles of simple structure, believed by plains of persistent and severe pruritus. In cases which him to be peculiar to the genital organs-are contained in have lasted a long time the vuilva region shrinks andl the clitoris. One lies on either side of the central line of becomes indurated. the glans, and these are more abundant on the upper The finger feels as if it were penetrating an inextenisive and surface. At the posterior part of the glans clitoridis, near rigid organ. Often milky-white opalescent spots are seen, its junction with the prepuce, there are a few Pacinian and having the appearance of leucoplakia. It is then knowii as a few Meissner's corpuscles. These nerve terminations white or leucoplakic kraurosis. are tlhe sensory organs of the vulva. Other forms of kraurosis have been described besides What we have to refer to is whether these local changes, the white kraurosis of Breisky. One of these is tlle red which for practical purposes may be described as leading kraurosis (Lawson Tait's kraurosis, inflammatory, vascular, to fibrosis of the nerves and nerve endings, and a kind of and follicular). Others are: Syphilitic, leucoplakic fibrous degeneration of the skin and subcutaneous tissues, kraurosisf "senile kraurosis," and "post-operative give rise to the pruritus, and are therefore primary, or kraurosis." This last form comes on after removal of whether they are due to the irritation caused by the con- the ovaries, and is of importance. With reference to the tinued friction. Those who have studied this disease will others, they are laid by some to ovarian insufficiency in most likely come to the general conclusion that all these the genesis of kraurosis. Some think it is owing to the changes in the tissues are due to irritation. It must, abolition of .the internal glandular secretion or to reflex however, be borne in mind that there are certain cases of nervous disorders, and others believe that secretory and intense irritation coming on in paroxysms, with no changes nervous troubles may act simultaneously. to be observed. My own experience leads me to say that Before leaving the subject of the pathology, I should like such attacks are merely tempor-ary and do not last. to state that my own opinion is that the disease arises in Whenever I have seen a case which has lasted any time, many cases owing to the Pacinian bodies, genital corpuscles, and-where scratching has taken place from the irritation, or Meissner's corpuscles being denuded of their epithelium ; certain changes can always be made out. from very- slight but irritating ulcers, which could not be It is thought by some to be conceivable13 that a diminu- made out by the naked eye; or from friction, and there- tion of the calcium content in the cutaneous tissue in the fore may be put down to " essential pruritus." We know neighbourhood of the nerve fibres may be recognized as a how sensitive these bodies are, and when exposed it is direct cause of the pruritus vulvae. The relations of urticaria conceivable that they may account for the attacks of to pruritus establish the importance of the disturbance of pruritus. calcium metabolism in the pathogeny of pruritus, for urti- PROGNOSIS. caria itself, according to Nesser, is comparable to a rupture This is often a matter of great difficulty. If the patient in the normal equilibrium of metallic ions. The appear- is seen in the early stages, there will often be no hesita- ance of pruritus under the influence of ingestion of citric tion in giving a favourable opinion as to the future. If, or oxalic acid in predisposed persons lends support to the however, the patient has suffered for a considerable time theory of a relation between the diminution of calcium in and there are already changes commencing in the skin and the tissues and the aforesaid disturbances, for the acids mucous membrane, muclh caution should be exercised, and take up this element. The same explanation attaches to it is only prudent to see the influence of treatment before the pruritus of icterus, in which the bile acids circulate in saying anything definite as to prognosis. It is perfectly the blood. certain that if a case has lasted for a considerable time a In the case of so-called essential pruritus one ought to cure is not likely to be rapidly effected, especially if the carefully ascertain tlle state of the organs regulating woman is unable or unwilling to follow exactly the calcium metabolism. Our knowledge in this direction is, of treatment recomnmended. course, limited, but Parhon thinks it feasible to affirm that among these organs the thyroid gland and the ovary play TREATMENT. an important part. The thyroid gland acts as a fixative And now, gentlemiien, we come to the practical part of agent of the calcium, whilst the ovary-the antagonistic this subject. The etiology and pathology may be very gland-acts as a decalcifying agent. According to this interesting, but what we have to ascertain is the mlost hypothesis of a disturbance in calcium metabolism, Parhon rapid method of getting tile patient well. The numiiber inclines to a thyroid deficiency, or excess of ftnction on of remedies used in the treatment of pr'Uritus vulvae the part of the ovary. is legion, and when this is the case, we may be quite sure It is right to mention that there are certain cases when that we have to deal with a disease requiring muclh time the woman only complains of pruritus vulvae at the time to be spent upon its treatment, and possibly many altera- of the period, or occasionally before the menstrual period tions in applications and drugs. A careful investigation of has commenced. In one case I have seen several times, each case, and an endeavour to study tlle etiology mliay the patient complained that the sense of irritation which greatly help towards treatment, and this is why causation led her to scrateh was referred to the vestibule at one should be regarded as of great importance. A thorouglh time, at another to the labia majora, and yet another, to examination in a good light may enable the cause to be the clitoris and mons veneris. This condition of temporary discovered at once, and such an examination siould never pruritus may be referred to probably local congestion of all be neglected. The proof of tile great importance of this the parts, brought about by the onset of menstruation. I examination is furnished by the fact that after weeks of have known cases where there has not only been pruritus treatment by ordinary means, the discovery of a minute of the vulva, but intense irritation of the mammae, especi- ulcer in the vestibule or elsewhlerQ, leading to tlle applica- ally the nipples, accompanied by swelling of those glands. tion of the Paquelin or electric cautery, may be followed Or the pruritus at this time may be due to the fact that by a rapid and complete cure. I think that the simplest just before the onset of menstruation a vaginal discharge plan of discussing the various means of treatlmient is to occTrs.It is, then, of importance to endeavour to find in divide the subject into treatment by (a) internal remedies, wliat way this discharge differs from the ordinary vaginal (b) by external remedies, and (e) operation. secr tion. Tllis may be done by an exploratory tampon befoi and after menstruation. I. TreatenrtbTInternal Reedies. In very slight cases of pruritus vulvae no internal Kraurosis. remedies may be necessary, for the remedies whiclh are I must mention the pruritus associated with kraurosis. usually applied externally will be sufficient. But in the This disease has been described by Breisky of Prague and more severe cases the nervous system is certain to be more -r Bh ls4 _- MARCH 2, IgT2. PRURITUS VULVAE. Xf- Jovu 473 or less disturbed. In the so-called "Essential Pruritus," say much about them. If anaemia is marked, iron in anv where no cause can be discovered, internal remedies are easily digestible form may be given, alone or in combina- of the utmost importance. But before giving any of them tion with manganese and haemoglobin. The main con- in detail, it is right to say a few words about diet. sideration must be to stop the paroxysmns of itching by It is unquestionable that in a certain number of cases any drugs which we know act on the nervous system, and dieting seems to be of value, but in most severe cases I if one is tried and gives no relief another must be sub- haive never found that it is of the smallest use. In some stituted. I have found benefit from the administration cases the patient'will at once tell you that certain articles of canuabin tannate in doses of from 3 to 5 grains three areinjuriousad apt to bring on an attack,or aggravate or four times in the twenty-four hours. Sometimes the existing condition. Individual experience in such cases chloretone, in doses of from 5 to 10 grains three times is of great value, ancd-ought to be taken into consideration a day after meals, has given great relief in a certain in prescribing. Generally speaking such articles as mus- number of cases, but the effect does not seemn to last long, tard,'curry, pepper, chutney, ginger, or any high-seasoned and after a comparatively short time improvement is not dishes ought to be avoided. Alcohol should be forbidden, maintained. Occasionally sumbul seems to afford relief for it certainly tends as a rule to aggravate the condition. in milder cases, but in severe forms ._it may not be of any In old waomen, however, it seems to be of benefit sometimes, service. In nmore than one case I bave given aspirin and where they have -beer accustomed to it all their lives, and novaspirin with marked benefit. Either miay be ordered wclree there is mnuch exhaustion. three times a day, witlh direction to take 10 grains if a I remember an old lady who used to have most terrible severe paroxysm comes on. In one very severe case the and cxhausting attacks, coming on usually before dinner, only drtug whiclh seemed to have any effect internally was when slie seemed to be tired and in want of food. She opium, which I gave in the form of pill containing 1 grain hardly ever took any form of stimulant, but when the three times a day. This was tried with benefit in a case attacks became frequent and led to exhaustion, she was of which was one of the most severe I have ever seen. As a opinion that a small quantity of alcohol was of benefit. rule opium and its preparations are not well borne. for, At any rate, she did not suffer quite so severely after taking although they seem to give temporary relief, the irritation it regularly. I am seeing another old lady now who-asures appears to be made worse in the long run; they must, me that on the days she goes without stimulant she feels therefore, be used with caution. worse and suffers niore from pruritus vulvae. I feel sure, Among the many drugs I have used internally I have however, that as a rule it is harmful in these cases. mentioned the above because they have appeared to do In addition to the foregoing articles I have mentioned, I more good than many others, but any nerve sedative may lhave known oysters, lobsters, crabs, and, in certain cases, be tried, and sometimes many will have to be tried before any kind of fish, intensify the attacks. It is a good rule, one which gives any relief at all is found. Occasionally therefore, in e-x.amining the patient for the first time, to any of the coal-tar analgesic remedies give relief and may ascertain if there is any special article of food or drink safely be tried for a time. Parhon and Panesco have which is apt to make the attacks more frequent or more found calcium chloride of use in pruritus. They con- severe. Occuii)ra'ly tea and coffee seem to bring on sider that a diminution of the calcium content in the attacks, and to render the patient worse, which should be cutaneous tissues in the neighbourhood of the nerve fibre sufficient ground for their exclusion as daily beverages. At may be recognized as a direct cause of the pruritus. If the same time I think it highly desirable with reference to there be a suspicion that the attacks are due to toxic any article of food or drink which may be mentioned as a absorption, salol and mercury in small doses may certainly possible cause of increasing, the irritation, to make quite be used with benefit. I believe they act both in the same sure that it is really the cause, for on investigation in manner, namely, as an antiseptic -to the contents of the certain cases I have satisfied myself that diet has had intestine. I may mention here that I have not had any nothing to do with the attacks. benefit from the administration of thyroid gland or of Before prescribing for patients suffering from pruritus ovarian substance. I have thought that the administration vulvae it is well to bear in mind that sometimes they may of ichthyol has given benefit. It may be given in 21. grain be sensitive to certain drugs, and it is prudent to ask if tabloids, and of these two may be taken after each meal. anything already prescribed has disagreed. I have known Before passing on to external treatment I must mention belladonna to bring on pruritus, and one patient under my the necessity of procuring sleep. A fairly large dose of care could never take any form of opium without suffering ammonium bromide, with adrachm of the tincture of from pruritus. Some consider these cases as toxic forms. hyoscyamus may produce refreshing sleep, and in a patient The important point to keep in view in prescribing internal worn out with constantly disturbed nights owing to remedies is to endeavour to stop the paroxysm of intense paroxysms of pruritus vulvae, a soothing draught given itching, and at the same time to order such drugs as we three or four nights running is often of the greatest know will act on the blood and nervous system, and pre- service. As sleep is of the highest importance in treating vent the patient becoming thoroughly run down, for the these cases, whatever drug will give the most refreshing disease in the long run is a most exhausting one. night may be used. Without a fair amount of sleep, In ordinary cases demanding internal treatment I should women suffering from pruritus vulvae soon show signs of certainly place bromides first. They have a soothing effect the nervous system beina affected by the development of on the nervous systenm, can be given in fairly large doses neurasthenia, intense irritability, etc. Morphine should alnd can do no harm. Ten grains of ammonium bromide, not be given, for as a rule it does not suit these patients. increasing the dose as may be deemed advisable, in com- Paraldehyde I have found of great service, commencing bination with bark, and sometimes arsenic, may be given with drachm, and increasing if necessary to 2 drachms, three times a day. I have sometimnes given large doses of in almond mixture. In cases where the patient awakes to ammonium bromide with good effect in cases where the find herself scratching, it is a good plan to have the nails paroxysms of itching have' been frequent and exhaust- cut very short and to wear soft gloves. ing. Sodium bromide or potassium bromide, or the Before commencing treatment by external application, mixed bromides, may be equally of service, but I have it is a good rule to have the vagina thoroughly douched formed the impression that when patients are taking with an antiseptic lotion, which can be omitted in the case ammonium bromide they are not so apt to become de- of unmarried women, the hair shaved away, the parts pressed as when taking the other bromides. It is said thorouglhly washed with soap and water, and then to use by some that strontium bromide may be taken for a some ether soap. This ensures thorough cleanliness of the considerable time without causing a bromide rash; and skin and mucous membrane before any application is this bears out my own experience. but it is by nio means attempted. to be relied on, for I have seen a bromide raslh appear soon after giving strontium bromide. If the continued II. Treatment by Extcrncal Riem edics. attacks of pruritus seem to be exhausting the patient It is natural to find in the treatment of this troublesome I have given some bromide twice daily, in the morning affection that all kinds of applications and lotions have and at bedtime, in addition to a pill containing phosphorus, been used, and that when one remedy lhas been of signal arsenic, and nux vomica, after meals. In certain cases service in the treatment of many cases it should be zinc valerianate seems to be of much benefit. The salts specially lauded. My belief is that success with certain of thoriumi- are said to be of service on account of their applications much depends on the time the pruritus has radio-activity, but I do- not know enough of their action to lasted and on the general state of the patient. In tho C TM DUN= NMI"& JounnAb 1- PRURITUS VULVAig. 474 [MARCH 2, 1912.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1912.. early stages, when the condition is not very troublesome, acid or oxalic acid afford relief, and the compound tincture and it is not considered necessary- to order medicine of benzoin, painted over' the affected parts, is of groat internally, a lotion of carbolic acid made up with spirit service. In certain cases the action of the preparations of and rose water, or vwith plain water, to be applied imme- tar is most beneficial. But it is well not to apply them in diately the itching begins, is valuable. The strength may the very early stages, as they are apt-to be not so beneficial begin at 2 per cent., and gradually increase until' the per- as in those cases which have lasted for some time. centage of carbolic acid is' sufficient to stop the itching In a certain number of cases I have found an application without itself causing irritation. It must be impressed of boracic acid, with white of egg, give great relief. I on the patient that if she is to get well quickly she 'must believe it acts by covering the sensitive parts with' a fine resist the temptation to scratch. There is only one way layer of albumen. Enough boracic acid to preserve the in which this can be done, and that 'is by having some albumen must be used. One of the most useful applica- lotion at hand which can be used quickly to stop the tions is menthol dissolved in paroleine. It may be used irritation. If once the patient has given way to the at the strength most suitable to the patient. It is best to temptation of scratching, nothing will stop her until the commence with a weak solution, 5 or 10 grains to the paroxysm is over and relief obtained. By the rapid ounce, and gradually to increase. If the 'attacks be at all application of whatever lotion is found efficacious the severe, nothing under 20 grains to the ounce will be strong intense irritation is arrested, and the patient will soon enough. I cannot speak too highly of this preparation, for learn that the self-restraint, however hard to practise, is it rarely fails to afford relief. of service to her, for the gratification of scratching is only Another preparation which I have had the greatest bought at the expense of torn and bleeding skin and satisfaction in using-where the pruritus vulvae has laste(d mucous membrane. If these cases are seen reasonably for some time is silver nitrate. This may be used in early, the secondary changes previously considered are not any strength up to 40 grains per ounce, and thorouglhly allowed to take place, for the patient is cured before they applied all over the part affected. commence. In nearly all cases which are seen early much In severe chronic cases I have painted the whole of the relief is afforded by bathing the parts affected with warm affected 'arts witlh the liquor epispasticus, with excellent starch and water. It is best to have this about the con- results. This, of course, entails rest in bed for a time. sistence of ordinary cream. This can be employed every Turning now to ointments, we find that there are a very night before going to bed. Some prefer to have this as a large number employed. In mild cases I-usually com- sitz bath, and to remain in it for five or ten minutes. mence with some bismuth ointment. and' if the attacks are Sometimes a bran bath answers the' same purpose. frequent, the addition of mercury subehlioride, 1 drachm Three or four pounds of bran are mixed with boiling water as to the ounce, is certainly of use. It is sometimes more an infusion. The bran is strained off, and the water added soothing if made up with elderfilower ointment. This may to the warm sitz bath. In some cases a gelatine bath is be applied freely at. bedtime, or at any time by day or preferred, or it can be mixed' with bran 'water. In a night. Some patients find that ointments afford more certain number of cases these baths are excellent, or alka- relief than any other kind of application, and therefore it line ones, containing sodium carbonate, borax, or potassium is best to change from one to another as soon as it is carbonate. But they are not always well borne, and this evident that improvement is not maintained, or that the is especially the case if there is a tendency to eczema of ointment prescribed is unsuitable. Cocaine vaseline, 5 to the vulva, where they must be used with caution. In 20 per cent., is often of immediate service, or it can be some cases ordinary soap should not be used in washing, made up with any other ointment, but the same remarks but milk or the yolk of an egg, which forms a lather and apply to it as to the solution. Speaking generally, it is does not irritate. most satisfactory to apply soothing ointments in recent Cocaine, beginning with a 5 per cent. solution and cases, and to reserve more stimulating ones for those increasing the strength if necessary, is often of great ser- which have lasted for some time. If the parts are red, vice. It may be commenced at any time, but it must be irritable, and evidently inflamed, any bland unirritating used with caution where there is any abrasion from ointment may be tried. It is unnecessary to mention scratching on account of the risk of absorption. I have anything like all the ointments which have been extolled formed the opinion, from frequent use in pruritus vulvae, in this formidable affection, but the ones I have derived that it cannot be continued long, for it seems to set up an most benefit from, in addition to those already mentioned, irritation of its own. -A severe sufferer for'whom I pre- are carbolic, of whatever strength seemed to suit the scribed it, told me that it was excellent at 'first, and gave patient, boracic, conium, chloretone and menthol. Occa- great relief, but that she felt sure it produced great sionally a plain alkaline ointment, containing sodium bicar- irritation, and she preferred after a time not to use it. bonate, or creta preparata, is most useful, and in certain Kromayer"5 speaks highly of the application to the cases ichthyol, salicylic, naphthalene, and iodine (stainless) affected parts of liquor potassae, which he says acts ointments are of service. causally by destruction of the subepidermoidal pruritus I must here mention that in those cases of so-called vesicles which are the source of the irritation. Solutions essential pruritus vulvae where the irritation seems to of corrosive sublimate sometimes rapidly stop the start high up in the vagina, the most soothing remedies paroxysms of itching. They may be used sufficiently arc douches and vaginal tampons. Perhaps the most strong as external applications, beginning with a weak satisfactory of the whole is a douche of carbolic acid, from solution, and increasing the strength if necessary, to 1 part in 60 to any strength which affords relief. Some- deaden the sensitive condition of the affected parts, and at times 1 drachm of liquor plumbi subacetatis to 1 pint of the same time weaker solutions may be employed for water, plain boracic, or a mixture of sodium bicarbonate vaginal injections, as 1 in 2,000 or 4,000. Solutions of and elderflower water, with a little hydrocyanic acid, form lead subacetate are often of use. Any remedy which excellent douches. Chloretone affords relief in some cases, quickly deadens the sensitiveness of the affected parts will given in a douche 0.5 per cent. in warm water. The tem- be the most efficacious, because on this rapid action of the perature of the water must be regulated according to the remedy in cutting short the paroxysm will its success patient's inclination. Although hot douches as a rule are depend. It is for this reason that certain sprays are agreeable, some prefer the temperature comparatively useful, such as that of ethyl chloride, ozonic ether and cool. In some cases where vaginal douching is agreeable, chloroform. They are, however, although useful, not if it takes too long to get the douche ready, then vaginal always at hand by day, if the patient is able to go about, tampons are often of great service. The patient knows and therefore a solution is as a rule more convenient. that the more quickly the remedy is used the more Sometimes the ordinary eau de Cologne, which is often at speedily the pruritus will disappear. It is easy to saturate hand, may be used if the patient is not within reach of a tampon to which a string is attached with any solution, the solutions prescribed. Any soothing evaporating lotion and insert it. I have found sometimes a weak solution of may give more relief than anything else. Equal parts of iodine speedily allay the irritation, but any of the above- water and eau de Cologne will make an agreeable lotion, mentioned remedies may be used. which can be applied on lint which is frequently saturated Powders dusted on are in some cases more appreciated with the lotion. It is prudent to be sure that there are no than any other kind of application. As a rule, however, ulcerations or excoriations from scratching, for otherwise they are not so effective as lotions or ointments. Occasion- all spirit applications may cause considerable irritation, ally I find that patients prefer ointment by night and he which lasts for some time. Occasionally solutions of citric application of powders by day, as being more convenient. 2, PRURITUS VULVAE. MARCCH 1912.j r ICA JOUR 475 Powders slhould all be triturateq to render them as fine as be extensive or large patches of ulceration the cauter"y possible, otherwise thev are apt to increase irritation. Of may be lightly applied over.the w*hole surface; where thlese 'applicatioins, finely powdered& boracic acid by itself, there are chronic changes in 1h3 skin and mucous mem- or mnixed with other powders, is very useful. Starch or brane of long standing, and no ulceration, T do not French chalk, with zinc oxide and boracic acid, with or consider the cautery as good as the-knife. witlhout calamine, makes an excellent application. To this (b) If the. cautery has been used and has failed, and the may be added chloretone, or finely powdered opium, if patient shows indications of failing health Qn account.of some more soothing application is required. In some cases the constant wear and tear of body and mind, the affected finely powdered calomel will afford relief and rapidly parts should be excised. Should there be one pateh in the bring about a cure. vestibule or elsewhere which the patient is certain is the I must here mention the injection of Schleich's fluid, starting point of the pruritus valvae,-it can be dissected composcd of eucaine, into the sacral canal. Schubert16 off, and the edges brought together with catgut. But if has writtenl an interesting paper on the subject, citing there be extensive changes, it will be best to freely cases which were successful, but I have not tried this remove the whole of the diseased parts, as suggested by method, and cannot do more than refer to it. Schroeder,19 including the clitoris, nvymphae, and tlle In addition to the foregoing, I may mention the treat- adjacent parts of the labia majora. During this operation m-ent by ultra-violet rays, high frequency current, elec- every diseased part must be removed. The remaining tricity, tlle Roent-gen rays, radium, and cataphoresis. tissues are then drawn inwards, and attached to the Time will not permi't of my doing mbre than mention mucous rnembrane of the vagina. these. I have tried them all, with the exception. The most serious operation of all is the division of of the ultra-violet rays. Eltze'7 speaks highly of the nerves, for althouglh theoretically it ought tojhe excellent treatment of pruritus vulvae by thie Roentgen rays, and treatment, yet practically the operationi requires much quotes cases. I confess that I have been disappointed in consideration on account of the possibilities involved. Sir its use in somue cases, but it certainly seenis to do good James Y. Simpson is said to lhave been the first to suggest whe're tllere are thickened patches of tissue giving rise to the division of nerves, but he credits Dr. Burns of Glasgow constant irritation. Some years ago I tried electricity in as being the first. to recognize " neuralgia and hyper- hospital l)atients, and considered that the continuous aesthesia of the vulva, and to cut the pudic nerve for it." current was certainly of some benefit in somee cases. According to Hirst2' the incisions of Burns could not have Cbolmogoroff "I had great success 'witlh the galvanic touched the pudic nerve, and the modification by Simpson current. Siebourge' (quoted by Veit) recommends' the of the operation by Burns he considers was still less likely subcutane'ous injection of physiological saline solution to injure the nerve. Since Simpson's time the pudic nerve over thie area at'which the itching is worst. I have tried has ieally been resected in some of the later operations, this tieatment', but do not considei that I have used it but tle disadvantages of this resection are that thpre is sufficiently long to say much about it, although it certainly danger of depriving the sphincter ani of its innervation, stops the irritation for a time. and so producing incontinence, and of not depriving the I have formed a good opinion of the treatment by vulva of its sensory nerve supply, which has been referred cataphoresis, especially in cases where there is minute to before. This nerve supply can be cut off by four ul'ceration present. Occasionally there is a good deal of incisions, tw;o in the groin as for Alexander's operation and reaction after this application, so that it cannot be again two in the buttocks parallel with the ascending ramus of used for several davs, and sometirmes it is best to allow a the ischium, beginning just above the tuberosity and ex- week or ten days to elapse before repeating it. If a tending upwards for 2 in. If the clitoris is involved the patient presents herself for the first time with severe dorsal nerve must be resected just above the bifurcation pruritus vulvae, and with a history of all kinds of treat- of the pudic nerve into its two branches. ment, by far the best course to pursue is to let her go to In advising this operation for the patient we must bear bed and be properly nursed. The parts may be thoroughly in mind tllat the last state of the woman may be worse covered, so as to prevent friction and exposure to the air, than the first, and that, in our anxiety to. cure the pruritus by some suitable application, such as a paste composed of vulvae, we must not fail to take into consideration the calamine and zinc oxide. likelihood of atrophy of all the parts with cevelopment of I have derived much satisfaction from the use of kraurosis vulvae and possibly the occurrence of epithelioma, pellanthum, which contains zinc oxide and zinc oleate. It which is occasiQnally seen with kraurosis. In the rare can be applied freely, and forms by itself a soothing and cases in which I. have been "asked for my opinion with adlheient film, which can be easily removed. It can be reference to this operation for division of the nerves I m-nixed with carbolic acid, menthol, or whatever may be have decided against it, for I have felt that we have not desired, and protects the affected parts fromn the atmo- yet had sufficient experience to speak with certain,ty of its splhere and from the risk of friction and irritation, and this results and the consequence of the anaesthesia of the is greatly assisted by complete rest in bed. It is some- vulva followiing on tlle operation. times quite extraordinary how well patients who have REFERENCES-.. been suffering for' considerable periods progress if these 5Bronson: Etiology of Itching, Med Record, October 24th, 1891. conditions be carried out. Itching Its Occurience both as a Concomitant and Cause of Disease. and Treatmient, MlJed.. ews, April 18th, 1903. Su'pposifig tha-t udine of the abbve remedies are of 2 Bov6e: Practice of Gynaecology, 1p. 265. service, somle persons who are tired of treatment and long 3 Seelignia,n: Prurituis Vulvae, Dentt. med Wocl1., 1902. 4Sitiger: Zeit. f. Gyjn.. 1894, p. 154. foti a change of surroundings, and who caL afford it, may 5 Veit: Die Erkrankungein der Vulva: Pruritus Vulvae. Han&dbutcl wish to try foreign waters. In such case's, Franzensbad, der Gyvelkoloriie, B. iv, 2,1910. vitll its 'moor may prove of the muriated ( Matthews -Duncahn Ulceration of Lu-ipus of the Female Generative baths, benefit; Organ.s. Obstetrical Tra7isactions, vol. xxvii, p). 149. alkaline waters of Ems, Royat, etc., or the tlhermal 7 Sir F. Wallis: Snirery of thle Rectum, p. 9, alkaline waters of Vichy. In all these places excellent 8Stelwagon: Diseases of the Skisz, 1910. 9 Veit: 01. cit. arrangements will be found for carrying out local treat- 1( K. Czerwenka: Beitrag zur lpathologischen Anatomiiie der Vulviteg ment, and attention to the general healtlh will be taken (Pruritus Vulvae). Monats.f. Geb. 2i. Gyni., xvi, 1). 1Q13, 1902. W1webster: Laborat( r., Reports. Royal College of Physicians of illto account. Edinburgh, vol. iii, 1851. III. 1 Saenger: Op. cit. Operation. 53Parhon and Panesco: Contribtution at l'6tude dii traitement du And now we come to the final means at our disposal for prurit cutanee chronique avee quelques considerations sur la patlio- genie du prurit. Journl. cle Nhvrologie, Bruxelles, 1908, xiv, p. 181. treating whlat, in some instances, proves to be such a 14 Dalchle, Paul: Les Prurits vulvaires. Le Kraurosis Vulvae. Jourl7. formidable malady-namely, operative interference. This deim&l. et dIe clur. erat., Paris, 1908, lxxix, 11, 18. method of treatment mnay be divided into: l Kromayer: Die Behandlung des Pruritus cutanens insbesondere, des Prturitus ani. Dentt. meet. TVoch., 1908, No. 2, 34. form of 16Schubert, Gottshard: Ueber die neue Behandllsngsmethode des (a) The application of some cautery. Essentielen Prurltus Vulvae und anderer sakralnetirosen (Frauensnarzt (b) The excision of the affected parts. in Benthen v. Schl.). (c) Division of nerves. 17 Eltze Die Behandlung mit Roentgen-stralhlen bei einigeti gynitkoloschen Erkrankungen. Alte neue Gynnakologie Festschrift (a) Thle application of* Paquelin's, or the electric t. F. R. Wiss-kel, 1907, -. 110. 13Cholmogoroff: Cenwtrabi. f. Gyn2., 1891, vol. xv.i thermo-cautery is of the greatest value in treating thosq 19 Schroeder: Zicts. f. Geb. X,. GtJin. Bd. xi, p). 386. cases where minute ulceration is discovered. Sometimes '0EIirat: Susrgical Treatmenlt of Prulritus Vulvae, withl Report of a one application of either cautery may be 'the means of Case Cured by Resectionl of the Genito-crural Ilio-inguinal Sup)erior I'udendal and Sup)erficial P>erinhal Nerves. 1903. Barton Cooke Ililss curing a case which has lasted for many weeks. If there MI.D., Philadelphia, U.S.A. Amer. MUed.. 1903.