PRURITUS

Definition.—Pruritus is a functional affection of the skin, having
as its sole symptom itching, burning, or pricking sensations.

Symptoms.—Pruritus, or itching, as an associated symptom of
other cutaneous diseases attended by structural changes, is entirely

¹Weir Mitchell and Spiller, Amer. Jour. Med. Sci., 1899, vol. cxvii, p. 1 (with
histologic cuts, review of the subject, and full references).

² There is sometimes considerable similarity in the cutaneous symptoms of these
various vasomotor and other nerve disorders. Erythromelia is another, which, as Pick
(“Ueber Erythromelie," Ergänzungsband (Kaposi’s Festschrift), Archiv, 1900, p. 915,
with colored plate and references to other cases) states, has in the objective and patho­
logic characters a slightly suggestive relationship to erythromelalgia, although quite dis­
tinct. This peculiar affection, which is rarer than erythromelalgia, Pick summarizes as
a symmetric, painless, cutaneous condition, more or less circumscribed, with progressive
livid redness radiating from the central part toward the periphery, and seated on the
extensor surfaces of the legs and arms, showing venous dilatation, but with no further
changes in the skin; Klingmüller and Rille (quoted by Pick) have observed retrogressive
atrophy, and others have noted a partial disappearance of the malady.

³ Lewin and Benda, Berlin, klin. Wochenschr., 1894, pp. 53, 87, 117, and 114 (a
critical review with references); Voorhees, “Erythromelalgia: A Study of 70 Cases Re­
ported in the Literature,” Jour. Amer. Med. Assoc., 1907, vol. xlviii, p. 1837, believes, as
Lewin and Benda, that it is not an independent disease, but a symptom-complex, which
may have either a central or peripheral origin.

⁴Moleen, Jour. Amer. Med. Assoc, Aug. 17, 1912, p. 532 (with review and refer­
ences).

⁵ Kanoky and Sutton, Jour. Amer. Med. Assoc., Dec 19, 1908, p. 2157.

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943

distinct from the affection under consideration. In this malady it is
the sole and essential symptom, with no other sign or feature except
those which may sometimes arise secondarily. There are, therefore,
no primary structural lesions, but in severe and persistent cases the
parts sometimes become so irritated by continued scratching and rub­
bing to which the pruritus gives rise that secondary lesions, such as fol-
licular papules and slight thickening and infiltration may result. As a
rule, however, excepting often evidences of scratching, pruritus remains
the only recognizable feature of the malady. The character of this
symptom varies somewhat in different individuals and sometimes
from time to time in the same individual. Most commonly it consists
purely of itching of variable degree, from slight to intense, occasionally
of almost intolerable severity. In others it is a feeling of tingling, prick­
ing, stinging, heat, or burning. In exceptional cases it is described as
similar to formication, as though insects were crawling over or in the
skin. It is occasionally constant, with but slight intermitting abate­
ment, but is usually more or less paroxysmal, and, as a rule, much
worse toward evening and the early part of the night. The desire to
scratch is often irresistible, and in consequence, as already remarked,
a variable degree of irritation may in some instances finally be pro­
voked, although commonly nothing more than slight hyperemia, trifling
harshness or roughness, with few or many linear scratch-marks or
punctate jags made by the finger-nails. It is to be said, however, that
in the vast majority of cases the skin remains free from lesions, except
possibly scattered excoriations. It is by far more frequent in those of
advanced years (pruritus senilis), especially those whose integument
begins to show some of the old-age changes. The itching may be more
or less general (generalized pruritus; pruritus universalis), or it may be
localized or limited in extent (local pruritus; pruritus localis). It is
rather exceptional to find it involving the whole surface, but is quite
frequently found confined to a large region, such as the trunk, limbs,
and especially the legs. Sometimes, on the other hand, it is limited to
a small area, such as the nose, the ear, the palms or soles, and other
locations to be referred to.

It is not at all uncommon to find it restricted to the genital region.
In men the scrotum may be its only seat (pruritus scroti), sometimes
extending along the perineum; or it exceptionally restricts itself to the
urethral orifice. It is probably more frequent during active adult life.

In women the whole vulvar region (pruritus vulvæ) may be subject
to paroxysmal or more or less persistent itchiness, sometimes chiefly
or wholly limited to the labia, clitoris, or even the outer end of the
vaginal canal. It may be met with in young children, due to the pres­
ence of intestinal worms, but it is usually observed in women of middle
or advanced life. The itching is often most distressing, the desire to
scratch frequently irresistible, so that such patients are often obliged
to shun society. In persistent and severe cases, from the constant
scratching or rubbing, a veritable eczema sometimes eventually develops.

Another locality often the site of pruritus is the anus (pruritus ani),
and here it is often of an intense character, but, as a rule, more or less

944

NEUROSES

paroxysmal. The anus often has a sodden look, that is usually associ­
ated with a foul-smelling secretion (Bronson). It is not infrequently
associated with hemorrhoids (itching piles). All ages and both sexes are
liable, but it is more common in active adult life and advanced years and
in males. In marked cases of pruritus ani Adler¹ states that a charac­
teristic condition of the disease is the loss of the natural pigment of the
part. In all probability, however, this is merely coincidental.

In addition to the several local varieties named, a few others should
be mentioned. Pruritus hiemalis (winter itch, frost itch), to which
Duhring² originally and subsequently others (Hutchinson, Payne,
Porras, Corlett)³ called attention, is a somewhat peculiar type. It is
commonly confined to the lower extremities, although occasionally in­
volving the arms also, arid exceptionally other parts. It is observed,
as a rule, only in adults, and presents in the beginning cool weather, in
October or November, and often persists until late spring. It is not
constant, but usually comes on at night, when the patient is disrobing,
after having undressed, or just after retiring. The itching varies in
different cases, but it is frequently quite intense, and the desire to scratch
cannot usually be restrained. After a variable paroxysm, lasting some
minutes to an hour or more, during which time the patient often scratches
and rubs considerably, relief finally comes. The next night the paroxysm
recurs, and so on, in most instances nightly. In some cases there may be
a recurrence when the patient rises, and exceptionally it may be more or
less persistent during the whole night. It is rarely present or troublesome
at other times. As a result of the rubbing and scratching the legs, in
severe instances, become somewhat rough, hyperemic, and excoriated,
the hairs often torn or broken off close to their follicles, and in rare ex­
amples the parts may finally present a slightly eczematous aspect.
The malady often varies in severity, and its intensity is lessened during
periods of milder weather, and sometimes disappears entirely during
such times, to reawaken as soon as the weather becomes colder. So it
continues in most cases all winter, finally disappearing as late spring
approaches, and remains in abeyance until the following autumn. In
other instances it continues for several weeks and then becomes milder
and finally disappears.

It is believed that some of the cases of so-called “prairie itch” " swamp
itch” “lumberman’s itch” “Ohio scratches” “Texas mange” etc, are
examples of pruritus hiemalis, possibly modified or aggravated by the cold
and windy, hard outdoor life, and the rough and often dyed character
of the cheap woolen underwear.⁴ Others of this group prove to be cases
of scabies, but probably the largest number are cases of dermatitis due
to the small mite, pediculoides ventricosus (q. v.), occasionally found with

¹ Adler, “Etiology, Symptomatology, and Treatment of Pruritus Ani,” Philada.
Polyclinic, 1895, Nos. 39, 43, and 50 (review of the subject, with references).

² Duhring, Philada. Med. Times, Jan. 10, 1874.

³ Hutchinson, Brit. Med. Jour., 1875, ii, P. 773; Payne, ibid., May 7, 1887; Morago
Porras, Trans. Internat. Cong. Derm, and Syph., 1889, p. 911; Corlett, Jour. Cutan.
Dis., 1891, p. 41.

⁴ Hyde, “On the Affections of the Skin Induced by Temperature Variations in Cold
Weather,” Chicago Med. Jour, and Exam., March, 1885, and Feb., 1886; also Hyde and
Montgomery, Diseases of the Skin, fifth edit., p. 758.

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945

straw and grain—the dermatitis variously known as “straw itch,'’
“grain itch,” “grain-mite dermatitis,” etc.

Another variety of pruritus (bath pruritus)¹ is that associated with
baths, a number of examples of which have come to my notice from time
to time. The itching or burning immediately follows a bath. The
sensation varies greatly even in the same individual, sometimes being
relatively slight, at other times intense. The feeling is one of pricking,
burning, or almost intolerable itching. It is usually aggravated if the
patient yields to the desire to rub or scratch violently. While it may ex­
ceptionally be general, it is commonly seated in the legs, from the hips
down, and occasionally in the forearms also. The attack lasts from sev­
eral minutes to half an hour or longer, becoming increasingly intense
and then gradually subsiding. It is usually of longer duration when the
patient goes directly from the bath to his bed; if his clothing is immedi­
ately donned, the pruritus will generally be less unbearable, less marked,
and of much shorter duration, especially if he walks about, so as to get
the soothing effect of the gentle rubbing of the underwear. It is met
with in adolescence and adult life, and, according to my observations,
chiefly in males, and in those having an irritable and dry skin.

Etiology.—The most common factors to be considered as of
probable import in more or less generalized pruritus are digestive and
intestinal derangements, hepatic disorders, intestinal worms, uric acid
excess or saturation, Bright’s disease, ovarian or uterine functional or
organic diseases, diabetes mellitus, carcinoma, tuberculosis, gestation,
and a depraved state of the nervous system. Of these, the first two are
most frequently causative. It has long been recognized that pruritus
is often associated with jaundice. Certain dietetic and medicinal agents,
such as named as sometimes etiologic in urticaria, are also occasionally
provocative. Especially opium and its alkaloids, and cocain are among
the drugs most apt to give rise to pruritus and particularly in those ad­
dicted to hypodermic abuse of morphia and cocain; the latter drug
not only giving rise to pruritus, but to sensations of insects burrowing
and crawling in the skin. In those of advancing years (pruritus
senilis), as already stated, the degenerative changes which the skin
undergoes are doubtless an important factor in these patients. Ac­
cording to Bronson,² who has given the subject careful consideration
“Of the general conditions that act as predisposing causes of pruritus,
whether it occur as an essential disease or is predominated by some other
disease of which it is a symptom, by far the most important is hyperes-
thesia. This may be either congenital or acquired, and either local or
general. It may be acquired through diseases that affect the economy at
large, or that are localized in the skin. The general diseases producing
it may be idiopathic neuroses, such as hysteria or hypochondriasis and
other affections of the nervous centers, or general nutritive diseases

¹ Stelwagon, “Bath Pruritus,” Philada. Med. Jour., Oct. 22, 1898.

²Bronson, “Etiology of Itching,” Med. Record, Oct. 24, 1891, and “Itching; Its
Occurrence Both as a Concomitant and Cause of Disease, and Treatment,” Med. News,
April 18, 1903. See also papers by McCall Anderson and Brooke, on “The Pathology
and Treatment of Pruritus,” Brit. Jour. Derm., 1895, pp. 292 and 294.

60

946                                       neuroses

affecting the nervous system secondarily, such as arthritism or diabetes
mellitus. In all the cases the primary effect of the general disease is
simply greatly to heighten the susceptibility of the peripheral nerves,
causing exaggerated sensations from the slightest contacts. The exciting
causes consist of irritations that may be either indirect and conveyed to
the skin from the interior of the body, or direct, in which case the ex­
citation is produced by local irritants, whether arising from extraneous
sources or from sources that are intracutaneous.”

The causes of localized forms of pruritus have in part been incidentally
referred to. Pruritus vulvæ in children may be due to intestinal worms,
especially ascarides in the rectum, and exceptionally even in the vagina
itself. The same causes are possible, although less likely in women.
Leukorrheal discharge is also sometimes provocative. Any irritation
or derangement of the utero-ovarian system may likewise serve as a
reflex cause. Diabetic urine, by its local irritating action, is sometimes
responsible for a vulvar pruritus, although, as a rule, in most instances
the itching is merely a part of an eczema which has been thus provoked.
It is not at all uncommon at the time of the menopause, during which
period it may be a reflex condition brought about by some nearby irrita­
tion of the utero-ovarian apparatus, or a part of a general neurosis. In
both sexes this localized pruritus is sometimes to be attributed to some
genito­urinary disease, such as vegetations or polypi or other irrita­
tion or stricture (Bangs) of the urethra, and to vesical calculi. Pruritus
ani, in addition to being frequently associated with hemorrhoids, as
already stated, may also be due to a fissure, fistula, or to hyperidrosis
of the part. Constipation, ascarides in the rectum, varicose condition
of the veins of this part of the bowel, and, in occasional instances, the
use of harsh or printed substances for toilet purposes may excite the
malady by the variable irritation thus produced (Adler).

In pruritus hiemalis cold weather is the essential factor, although,
according to my observations, it is to be observed chiefly in those whose
skin sweats but slightly and is lacking in the natural oiliness. Added
to these are to be mentioned gouty tendency and defective digestion, and
the irritation of rough woolen underwear. In bath pruritus the actual
cause is the water, although certain factors, in some cases at least, have
an influence. Strong soaps tend to aggravate it, and mild soaps, if used
in too great freedom or if not fully rinsed off, seem also to have a damaging
effect. Long continuance in the water will usually promote and aggra­
vate an attack. Very hot or very cold water is also an aggravating
influence in some individuals, although, as a rule, the active factor is the
bath itself, independently of the temperature of the water. It is observed
chiefly, if not entirely, in those who have a naturally dry, harsh, and
irritable skin. Those affected are distinctly those of a nervous tempera­
ment, weak digestion, and lithemic tendencies.

Pathology.—The disease is a sensory neurosis. There is nerve
disturbance, without associated appreciable structural change, and the
provocative irritation may be either of reflex origin or direct, and may
have its seat at any part of the nervous system from center to periphery.
The tissues remain unaltered throughout the entire course of the malady,

PRURITUS

947

except so far as secondary conditions are, in some instances, brought
about by the persistent scratching and rubbing.

Diagnosis.—The subjective symptom of itching without the pres­
ence of structural lesions is diagnostic. In those severe and persistent
cases in which excoriations and papules have resulted from the scratch­
ing, the history of the case, together with its behavior and course, must
be considered. Care should be taken not to confound it with pedicu­
losis, which is possible in those instances of the latter showing relatively
slight reactionary irritation; in most cases of pediculosis, however, the
excoriations, often with intermingled papules and pustules, and their
peculiar distribution, being most abundant on those parts of the body
with which the clothing comes in contact, as especially across the shoul­
ders, upper part of the back, around the wrist, and outer aspects of the
limbs are quite characteristic. In suspected cases inner garments, and
especially the seams, particularly of the neck­band, should be examined
for pediculi. The lesions of scabies and the distribution will prevent
confusion as to this malady. The possibility of itchiness being due to
other parasites, such as bed-bugs, fleas, gnats, etc., must be borne in
mind, but in such instances, as in the other parasitic affections already
named, the presence of bites, lesions, distribution, and history will
usually suffice to prevent error. Urticaria can be distinguished by the
presence or history of wheals and its capricious character.

In pruritus of the genital region the first essential is to exclude its
being due to pubic lice. In this latter malady (pediculosis pubis), in
addition to excoriations, various lesions, such as papules and pustules,
are commonly to be found, and a careful search will discover ova on the
hair-shafts, and the parasites near or on the skin, usually grasping a hair.
Pruritus can scarcely be confounded with eczema, as the lesions, redness,
and infiltration of the latter are wanting. The mistake is most likely to
occur when about the vulva or anus, as here it is not uncommon for the
rubbing and scratching to bring about some infiltration; in fact, in some
instances a veritable eczema may be thus provoked.

Prognosis.—This depends, in great measure, upon the discovery
of the causes and the possibility of their removal or modification. The
malady is usually troublesome and often rebellious, although in the
majority of cases the condition responds to proper treatment. Pruritus
of the vulva is always obstinate, likewise that of the anus. Pruritus
hiemalis can at the best, as a rule, be only palliated or kept in abeyance,
but disappears spontaneously toward the advent of mild weather.
Bath pruritus permits usually of palliation, but absolute relief can scarcely
be promised without considerable qualification. Temporary relief can,
however, in all varieties, always be given by external applications.

Treatment.—In the treatment of this disorder the various pos­
sible etiologic factors of digestive and intestinal disturbance, hepatic
disorders, diabetes mellitus, the uric acid diathesis, renal and utero-
ovarian diseases, and a low state of the nervous system must all be con­
sidered. The constitutional treatment, if deemed advisable, will there­
fore depend upon the conclusion reached from a study of the individual
case. The diet should be plain and unstimulating, and, when neces-

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NEUROSES

sary, adapted to any special etiologic conditions which may exist. Alco­
holic drinks are usually harmful. In many instances a saline laxative
in the morning, with a dose of an alkali after each meal, will do much
toward relieving the patient. Moderately large doses of sodium salicylate,
salophen, or of the lithia salts will aid in cases dependent upon gouty or
rheumatic conditions. In many instances, it is true, it is difficult to
recognize any etiologic factor; in such, constitutional treatment must
be wholly experimental, quinin in large doses, pilocarpin, belladonna,
strychnin, cannabis indica, lupulin, calcium chlorid (Savill), and even
arsenic being tried. Cannabis indica, in the form of the tincture, 10 to
30 minims (0.65-2.) three times daily, as commended by Bulkley, and
subsequently by Crocker, can be tried in rebellious cases. Schamberg
commends moderate to full doses of carbolic acid. In those in which
the itching is intense and not sufficiently controlled by external applica­
tions anodynes must be given internally—potassium bromid, chloral,
sulfonal, cannabis indica, phenacetin, acetanilid, and antipyrin being
variously prescribed. The opium preparations are, as a rule, not well
borne, tending usually, after the narcotic effect has passed off, to in­
crease the itching. General galvanization, static insulation, and the
application of static electricity by the roller electrode down the spine
furnish relief in occasional instances.

The external treatment of pruritus is of great importance, and,
indeed, essential in almost all. cases. In most patients unirritating
underwear, such as cotton, lisle thread, silk, or linen, should be worn
next to the skin, as woolen garments are frequently an additional ex­
citing factor in these cases. Among remedial applications lotions are,
as a rule, most satisfactory, although in some patients the itching seems
to be due to a lack of oiliness of the skin, and, in this latter class, oint­
ments even of an extremely negative character often give relief. The
most commonly prescribed local remedial agent is carbolic acid; this is
applied usually in the form of a lotion as follows:

R. Acidi carbolici,                                               3j^_iij (4-12.);

Glycerini,                                                      f3ij (8.);

Alcohol,                                                         f3j (32.);

Aquae,                                                q. s. ad Oj (500).

Or, and more especially in the local varieties of pruritus, in an ointment
or oil, from 5 to 20 grains (0.33-1.33) to the ounce (32.) of petrolatum
or rose-water ointment or liquid petrolatum. Bronson prefers the use
of this drug in oil, and employs it in 12.5 to 25 per cent, proportion, which
he states may, with proper precautions, be used with perfect impunity,
provided the area to which it is applied is of moderate extent. His
favorite formula is 1 to 2 drams (4.-8.) of carbolic acid, 1 dram (4.)
liquor potassæ, and 1 ounce (32.) of linseed oil, to which a few drops of,
bergamot oil can be added. Dyer¹ commends a combination of car­
bolic acid, menthol, camphor, and chloral, which results in an oily sub­
stance, and diluting with any of the simple oils. Thymol is another
valuable application, used as an ointment, from 5 to 20 grains (0.33-
¹ Dyer, Jour. Arkansas Med. Soc’y., Aug., 1912.

PRURITUS

949

1.33) to the ounce (32.), or as a lotion, from 8 to 16 grains (0.52-1.)
to the pint (500.) of water, with sufficient alcohol and glycerin for its
solution. Resorcin is also valuable as a wash, from 3 to 10 grains (0.2-
0.65) to the ounce (32.), with a few minims of glycerin and alcohol.
Liquor carbonis detergens, with from 3 to 20 parts of water; and liquor
picis alkalinus, from 1 to 3 drams (4.-12.) to the pint (500.) of water,
are both of service in some cases.

To all these lotions the addition of 3 to 10 minims (0.2-0.65) of
glycerin to the ounce (32.) is often an advantage, as many of these
patients have rather dry skin; it should not be used, however, in large
proportion.

Alkaline baths, with from 1 to 4 ounces (32.-128.) of sodium car­
bonate, bicarbonate, or borate to the 30 gallons of water, in which the
patient lies for from ten to thirty minutes, are, more especially in those
with oily or not too dry a skin, not infrequently useful; after the bath
the patient taps himself dry with a soft towel, and applies a small quan­
tity of petrolatum, cold cream, or a bland oil, plain or medicated, as may
seem to be demanded; following this a dusting-powder of starch, rice-
flour, or corn-starch is to be freely dusted on. This should be repeated
every two or three days. In place of the bath, alkaline lotions contain­
ing one of the several alkalis named, of the strength of from \ grain
to 2 grains (0.033-0.13) to the ounce (32.), may be used, also to be fol­
lowed up with an oily application. A compound lotion, such as the
following, although smacking strongly of polypharmacy, has acted well
in some cases: R. Acidi carbolici, 3ij (8.); thymol, gr. xvj (1.); resorcini,
3ss-j (2.-4.); sodii boratis, 3ss (2.); glycerini, f3ij (8.); alcohol, f3j (32.);
aquæ, q. s. ad Oj (500.). In some instances acid lotions seem to act
well, consisting of 1 part of ordinary vinegar to 5 or 10 parts of water,
or of acetic acid 1 part to from 20, 30, or more parts of water. In other
cases the free use of a dusting-powder alone seems to protect the skin
from the air, and in this manner probably gives relief; powder applica­
tions may also be used as supplementary to lotions.

In the local varieties—pruritus vulvæ, pruritus scroti, and pruritus
ani—the various remedial applications already named often suffice to
give relief. All possible etiologic factors should be considered, and
any indicated treatment instituted. In addition to the applications
referred to, however, and probably of greater benefit, may be mentioned
menthol, applied as an ointment or in a bland oil, from 5 to 20 grains
(o.33-1.33) to the ounce (32.); an ointment or solution of cocain,
from 1 to 10 grains (o.o65-o.65) to the ounce (32.); anointment made
up of from ½ to 1 dram (2.-4.) each of chloral and camphor to the
ounce (32.) of simple cerate or petrolatum; and one consisting of from
½ to 1 dram (2.-4.) of chloroform to the ounce (32.) of simple cerate or
petrolatum. Tarry ointments, although disagreeable, are sometimes
quite serviceable in pruritus ani; after thoroughly rubbing in, the part
is wiped off and a simple dusting-powder applied. A free action of the
bowels should be maintained in pruritus ani, as well as, in fact, in all
varieties; in this form the salines or fluidextract of cascara sagrada can
be employed, and sulphur as a laxative is also often valuable in these

950

NEUROSES

cases. In pruritus vulvæ, especially in cases due to irritating discharges,
astringent applications and injections of alum, tannic acid, or zinc
sulphate, in the strength usually employed for vaginal injections, will be
found of service. Hot­water injections, repeated once or twice daily,
will also prove useful in some instances. Another plan of treatment which
has done good in some cases of the local forms of pruritus is the applica­
tion of a sinapism or small blister over the lower lumbar region (Crocker).
An occasional painting of the region with a 2 to 5 per cent, solution of
silver nitrate in sweet spirits of niter is of service in some instances.
As a temporary expedient to bridge over an intense paroxysm, dousing
the part with hot water, as hot as can be borne, can be resorted to.
The x-ray has proved of value in some cases of these localized forms of
pruritus. In persistent inveterate cases of pruritus vulvæ resection of
the supplying sensory nerves has been exceptionally practised (Hirst,
Deaver¹).

In that variety of pruritus due to temperature changes (pruritus
hiemalis) the several applications already enumerated may be tried;
in many instances the skin is dry and harsh and needs oil, and in such
the daily application of a plain ointment will give relief; or the addition
of 10 grains (0.65) of salicylic acid to the ounce (32.) will be found valu­
able; or a weak glycerin lotion, from 4 to 8 drams (16.-32.) to the pint
(500.) of water, may also act well. A combination that has served me
in some of these cases consists of equal parts of lanolin, petrolatum, and
benzoated lard, with 10 grains (0.65) of salicylic acid to the ounce (32.);
and in others the addition of from 3 to 10 grains (0.2-0.65) of menthol.
Underwear of non-irritating character is especially necessary in this form
of the malady, with sufficient outer woolen covering, however, for suffi­
cient warmth; cold, especially if combined with high winds, being dis­
tinctly etiologic.

In bath pruritus, as to the matter of treatment, unfortunately very
often but little more than palliation can be accomplished. The water
used should be between tepid and warm, neither hot nor cold. Excep­
tions to this rule will be observed, and some patients find the attack
slight or less severe after a cold bath and some after a hot bath. Soaps
should be mild and used sparingly, and be thoroughly rinsed off. The
parts should be wiped or preferably tapped gently dry with a soft towel;
it seems that if the skin is allowed to dry itself or is incompletely wiped
or tapped dry the itching is usually much worse. In some cases the
introduction of some substance into the bath, such as salt, in order to
bring it up to the specific gravity of the blood, is of value. The bath
should be of short duration. Application, by gently rubbing in, of a
glycerin lotion or of an ointment of cold cream and lanolin, with or
without a minute quantity of carbolic acid or thymol, will frequently
lessen the severity of, or exceptionally abolish, the attack. The free
use of a dusting-powder following the bath has also at times a palliative
influence. The attack will be less unbearable if the bath is taken at such
time as the patient immediately dresses and stirs about. Weak alkaline

¹ B. C. Hirst, Amer. Medicine, 1903, vol. v, p. 785; Deavcr (Discussion), Proceed­
ings of the Philada. County Med. Soc’y, April 30, 1903, vol. xxiv. No. 4.

ANESTHESIA

951

baths are sometimes less exciting than plain or soap-and-water baths..
The Turkish bath is not so likely to be followed by the pruritic attack
(Hall¹). Constitutional treatment should be advised, especially if there
seems to exist any of the predisposing factors mentioned. The bowels
should be kept free, a plain diet enjoined, the digestion carefully looked
after, and the nervous system kept in proper tone. In some of the cases
antilithemic remedies, especially moderate doses of sodium salicylate,
seem of positive value. A physician² reports the control of the affection
in himself by fair doses of arsenic.

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